Racial, Ethnic, and Socioeconomic Disparities in Access to Transcatheter Aortic Valve Replacement Within Major Metropolitan Areas

Abstract

IMPORTANCEDespite the benefits of high-technology therapeutics, inequitable access to these technologies may generate disparities in care.OBJECTIVE To examine the association between zip code-level racial, ethnic, and socioeconomic composition and rates of transcatheter aortic valve replacement (TAVR) among Medicare patients living within large metropolitan areas with TAVR programs. DESIGN, SETTING, AND PARTICIPANTSThis multicenter, nationwide cross-sectional analysis of Medicare claims data between January 1, 2012, and December 31, 2018, included beneficiaries of fee-for-service Medicare who were 66 years or older living in the 25 largest metropolitan core-based statistical areas.EXPOSURE Receipt of TAVR. MAIN OUTCOMES AND MEASURESThe association between zip code-level racial, ethnic, and socioeconomic composition and rates of TAVR per 100 000 Medicare beneficiaries.RESULTS Within the studied metropolitan areas, there were 7590 individual zip codes. The mean (SD) age of Medicare beneficiaries within these areas was 71.4 (2.0) years, a mean (SD) of 47.6% (5.8%) of beneficiaries were men, and a mean (SD) of 4.0% (7.0%) were Asian, 11.1% (18.9%) were Black, 8.0% (12.9%) were Hispanic, and 73.8% (24.9%) were White. The mean number of TAVRs per 100 000 Medicare beneficiaries by zip code was 249 (IQR, 0-429). For each $1000 decrease in median household income, the number of TAVR procedures performed per 100 000 Medicare beneficiaries was 0.2% (95% CI, 0.1%-0.4%) lower (P = .002). For each 1% increase in the proportion of patients who were dually eligible for Medicaid services, the number of TAVR procedures performed per 100 000 Medicare beneficiaries was 2.1% (95% CI, 1.3%-2.9%) lower (P < .001). For each 1-unit increase in the Distressed Communities Index score, the number of TAVR procedures performed per 100 000 Medicare beneficiaries was 0.4% (95% CI, 0.2%-0.5%) lower (P < .001). Rates of TAVR were lower in zip codes with higher proportions of patients of Black race and Hispanic ethnicity, despite adjusting for socioeconomic markers, age, and clinical comorbidities.CONCLUSIONS AND RELEVANCE Within major metropolitan areas in the US with TAVR programs, zip codes with higher proportions of Black and Hispanic patients and those with greater socioeconomic disadvantages had lower rates of TAVR, adjusting for age and clinical comorbidities. Whether this reflects a different burden of symptomatic aortic stenosis by race and socioeconomic status or disparities in use of TAVR requires further study.

Disparities in Cardiovascular Mortality Between Black and White Adults in the United States, 1999 to 2019

“…In addition, the dissemination of novel cardiovascular therapeutics lags behind in Black communities. 24,39,40 Even among those with adequate access to health care, the implicit and explicit biases of health care providers and systems may lead to lower-quality care (ie, cardiovascular disease risk assessment, screening, 41,42 and treatment recommendations). 35,43,44 We observed marked geographic variation in cardiovascular mortality in the United States.…”

Characterizing the Accuracy of International Classification of Diseases, Tenth Revision Administrative Claims for Aortic Valve Disease

“…Such algorithms could be used for hospital benchmarking and process improvement (eg, by intensifying resources for a population to prevent gaps in referral and treatment), evaluating healthcare utilization and treatment needs of individuals with AS/AR, improving knowledge about AS and its associated biological underpinnings, 19 and disaggregating diagnosis from treatment in the study of racial, ethnic, and sociodemographic disparities that exist in the receipt of TAVR. 10,20 Although limited to a single medical center, the current study indicates that coding for AS/AR remains inconsistent. Improved guidance for coding of AS/AR (particularly for subtypes of AS/AR such as bicuspid and rheumatic disease where specific codes exist already) and creation of new codes specific to the severity of AS/AR could potentially improve the utility of claims to evaluate AS/AR.…”

Predictors and risk-adjusted outcomes of new-onset postoperative atrial fibrillation in repeat surgical and valve-in-valve transcatheter aortic valve replacement

“…Black race was documented in this New York Statewide r-AVR population to be predictive of MM; per a prior publication of 991 TAVR patients, this may be due to black race also being associated with a patient-prosthesis mismatch [32] . Based on a study by Taylor et al, black patients who underwent a mitral valve replacement or an AVR were also significantly associated with an increased risk of procedural complications such as prolonged ventilation, longer postoperative stay, and reoperation for bleeding; these patients were generally in poorer health compared to white patients, with higher New York Heart Association class and pulmonary artery pressures and lower ejection fractions [33] . This disparity in health outcomes for black patients is likely due to limited access to care despite these patients residing near hospital centers that perform TAVR, as indicated by Nathan et al and Bilfinger et al [34,35] .…”