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Ismayl M, Ahmed H, Goldsweig AM, Eleid MF, Guerrero M. Economic Disparities in Utilization and Outcomes of Structural Heart Disease Interventions in the United States. JACC. ADVANCES 2024; 3:101034. [PMID: 39130026 PMCID: PMC11312775 DOI: 10.1016/j.jacadv.2024.101034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 04/26/2024] [Accepted: 05/03/2024] [Indexed: 08/13/2024]
Abstract
Background Disparities in access to care cause negative health consequences for underserved populations. Economic disparities in structural heart disease (SHD) interventions are not well characterized. Objectives The objective of this study was to evaluate economic disparities in the utilization and outcomes of SHD interventions in the United States. Methods We queried the National Inpatient Sample (2016-2020) to examine economic disparities in the utilization, in-hospital outcomes, length of stay, and cost of SHD interventions among patients ≥65 years of age. Outcomes were determined using logistic regression models. Results A total of 401,005 weighted hospitalizations for transcatheter aortic valve replacement, left atrial appendage occlusion, transcatheter mitral valve repair, and transcatheter mitral valve replacement were included. Utilization rates (number of procedures performed per 100,000 hospitalizations) were higher in patients with high income compared with medium and low income for transcatheter aortic valve replacement (559 vs 456 vs 338), left atrial appendage occlusion (148 vs 136 vs 99), transcatheter mitral valve repair (65 vs 54 vs 41), and transcatheter mitral valve replacement (7.7 vs 6.7 vs 1.2) (all P < 0.01). Low- and medium-income patients had distinctive demographic and clinical risk profiles compared with high-income patients. There were no significant differences in the adjusted in-hospital mortality, key complications, or length of stay between high-, medium-, and low-income patients following any of the 4 SHD interventions. High-income patients incurred a modestly higher cost with any of the 4 SHD interventions compared with medium- and low-income patients. Conclusions Economic disparities exist in the utilization of SHD interventions in the United States. Nonetheless, adjusted in-hospital outcomes were comparable among high-, medium-, and low-income patients. Multifaceted implementation strategies are needed to attenuate these utilization disparities.
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Affiliation(s)
- Mahmoud Ismayl
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Hasaan Ahmed
- Department of Internal Medicine, Creighton University School of Medicine, Omaha, Nebraska, USA
| | - Andrew M. Goldsweig
- Department of Cardiovascular Medicine, Baystate Medical Center, Springfield, Massachusetts, USA
| | - Mackram F. Eleid
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Mayra Guerrero
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Hoagland A, Kipping S. Challenges in Promoting Health Equity and Reducing Disparities in Access Across New and Established Technologies. Can J Cardiol 2024; 40:1154-1167. [PMID: 38417572 DOI: 10.1016/j.cjca.2024.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 02/20/2024] [Accepted: 02/21/2024] [Indexed: 03/01/2024] Open
Abstract
Medical innovations and novel technologies stand to improve the return on high levels of health spending in developed countries, particularly in cardiovascular care. However, cardiac innovations also disrupt the landscape of accessing care, potentially creating disparities in who has access to novel and extant technologies. These disparities might disproportionately harm vulnerable groups, including those whose nonmedical conditions-including social determinants of health-inhibit timely access to diagnoses, referrals, and interventions. We first document the barriers to access novel and existing technologies in isolation, then proceed to document their interaction. Novel cardiac technologies might affect existing available services, and change the landscape of care for vulnerable patient groups who seek access to cardiology services. There is a clear need to identify and heed lessons learned from the dissemination of past innovations in the development, funding, and dissemination of future medical technologies to promote equitable access to cardiovascular care. We conclude by highlighting and synthesizing several policy implications from recent literature.
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Affiliation(s)
- Alex Hoagland
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Ontario Shores Centre for Mental Health Sciences, Toronto, Ontario, Canada.
| | - Sarah Kipping
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Ontario Shores Centre for Mental Health Sciences, Toronto, Ontario, Canada
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3
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Li R, Prastein DJ, Choi BG. Socioeconomic disparity in transcatheter and surgical aortic valve replacement: a population study of National Inpatient Sample from 2015 to 2020. Sci Rep 2024; 14:11762. [PMID: 38783030 PMCID: PMC11116551 DOI: 10.1038/s41598-024-62797-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 05/21/2024] [Indexed: 05/25/2024] Open
Abstract
There is limited data on the effect of socioeconomic status (SES) on transcatheter (TAVR) and surgical aortic valve replacement (SAVR) outcomes for aortic stenosis (AS). This study conducted a population-based analysis to assess the influence of SES on valve replacement outcomes. Patients with AS undergoing TAVR or SAVR were identified in National Inpatient Sample from Q4 2015-2020. Multivariable logistic regressions were used to compare in-hospital outcomes between patients living in neighborhoods of income at the lowest and highest quartiles. Of 613,785 AS patients, 9.77% underwent TAVR and 10.13% had SAVR. These rates decline with lower neighborhood income levels, with TAVR/SAVR ratio also declining in lower-income areas. Excluding concomitant procedures, 58,064 patients received isolated TAVR (12,355 low-income and 15,212 high-income) and 43,694 underwent isolated SAVR (10,029 low-income and 10,811 high-income). Low-income patients, in both TAVR and SAVR, were younger but had more comorbid burden. For isolated TAVR, outcomes were similar across income groups. However, for isolated SAVR, low-income patients experienced higher in-hospital mortality (aOR = 1.44, p < 0.01), pulmonary (aOR = 1.13, p = 0.01), and renal complications (aOR = 1.14, p < 0.01). They also had more transfers, longer waits for operations, and extended hospital stays. Lower-income communities had reduced access to TAVR and SAVR, with TAVR accessibility being particularly limited. When given access to TAVR, patients from lower-income neighborhoods had mostly comparable outcomes. However, patients from low-income communities faced worse outcomes in SAVR, possibly due to delays in treatment. Ensuring equitable specialized healthcare resources including expanding TAVR access in economically disadvantaged communities is crucial.
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Affiliation(s)
- Renxi Li
- The George Washington University School of Medicine and Health Sciences, 2300 I St NW, Washington, DC, 20052, USA.
| | - Deyanira J Prastein
- The George Washington University School of Medicine and Health Sciences, 2300 I St NW, Washington, DC, 20052, USA
| | - Brian G Choi
- The George Washington University School of Medicine and Health Sciences, 2300 I St NW, Washington, DC, 20052, USA
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4
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Fogelson B, Baljepally R, Heidel E, Ferlita S, Moodie T, Coombes T, Goodwin RP, Livesay J. Rural versus urban outcomes following transcatheter aortic valve implantation: The importance of the heart team. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024; 62:3-8. [PMID: 38135570 DOI: 10.1016/j.carrev.2023.12.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 12/12/2023] [Accepted: 12/13/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND Rural patients face known healthcare disparities and worse cardiovascular outcomes compared to urban residents due to inequitable access and delayed care. Few studies have assessed rural-urban differences in outcomes following Transcatheter Aortic Valve Implantation (TAVI). We compared short-term post-TAVI outcomes between rural and urban patients. METHODS We performed a retrospective analysis of n = 413 patients who underwent TAVI at our large academic medical center, between 2011 and 2020 (rural/urban patients = 93/320. Rural/urban males = 53/173). Primary outcomes were all-cause mortality and cardiovascular mortality. Secondary outcomes included stroke/transient ischemic attack, myocardial infarction, atrial fibrillation, acute kidney injury, bleeding, vascular complications, and length of stay. RESULTS The mean age in years was 77 [IQR 70-82] for rural patients and 78 [IQR 72-84] for urban patients. Baseline characteristics were similar between groups, except for a greater frequency of active smokers and diabetics as well as a greater body mass index in the rural group. There were no statistically significant differences in all-cause or cardiovascular mortality between the groups. There was also no statistically significant difference in secondary outcomes. CONCLUSION Rural and urban patients had no statistically significant difference in all-cause mortality or cardiovascular mortality following TAVI. Given its minimally invasive nature and quality-centric, multidisciplinary care provided by the TAVI Heart Teams, TAVI may be the preferred modality for the treatment of severe aortic stenosis in rural populations.
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Affiliation(s)
- Benjamin Fogelson
- Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA.
| | - Raj Baljepally
- Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
| | - Eric Heidel
- Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
| | - Steve Ferlita
- Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
| | - Travis Moodie
- Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
| | - Tyler Coombes
- Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
| | - Rachel P Goodwin
- Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
| | - James Livesay
- Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
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Gupta A, Mori M, Wang Y, Pawar SG, Vahl T, Nazif T, Onuma O, Yong CM, Sharma R, Kirtane AJ, Forrest JK, George I, Kodali S, Chikwe J, Geirsson A, Makkar R, Leon MB, Krumholz HM. Racial/Ethnic Disparities in Aortic Valve Replacement Among Medicare Beneficiaries in the United States, 2012-2019. Am J Med 2024; 137:321-330.e7. [PMID: 38190959 PMCID: PMC11019903 DOI: 10.1016/j.amjmed.2023.12.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 12/18/2023] [Accepted: 12/20/2023] [Indexed: 01/10/2024]
Abstract
PURPOSE There are concerns that transcatheter or surgical aortic valve replacement (TAVR/SAVR) procedures are preferentially available to White patients. Our objective was to examine differences in utilization of aortic valve replacement and outcomes by race/ethnicity in the US for patients with aortic stenosis. METHODS We performed a serial cross-sectional cohort study of 299,976 Medicare beneficiaries hospitalized with principal diagnosis of aortic stenosis between 2012 and 2019 stratified by self-reported race/ethnicity (Black, Hispanic, Asian, Native American, and White). Outcomes included aortic valve replacement rates within 6 months of index hospitalization and associated procedural outcomes, including 30-day readmission, 30-day and 1-year mortality. RESULTS Within 6 months of an index admission for aortic stenosis, 86.8% (122,457 SAVR; 138,026 TAVR) patients underwent aortic valve replacement. Overall, compared with White people, Black (HR 0.87 [0.85-0.89]), Hispanic (0.92 [0.88-0.96]), and Asian (0.95 [0.91-0.99]) people were less likely to receive aortic valve replacement. Among patients who were admitted emergently/urgently, White patients (41.1%, 95% CI, 40.7-41.4) had a significantly higher aortic valve replacement rate compared with Black (29.6%, 95% CI, 28.3-30.9), Hispanic (36.6%, 95% CI, 34.0-39.3), and Asian patients (35.4%, 95% CI, 32.3-38.9). Aortic valve replacement rates increased annually for all race/ethnicities. There were no significant differences in 30-day or 1-year mortality by race/ethnicity. CONCLUSIONS Aortic valve replacement rates within 6 months of aortic stenosis admission are lower for Black, Hispanic, and Asian people compared to White people. These race-related differences in aortic stenosis treatment reflect complex issues in diagnosis and management, warranting a comprehensive reassessment of the entire care spectrum for disadvantaged populations.
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Affiliation(s)
- Aakriti Gupta
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, Calif; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Conn
| | - Makoto Mori
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Conn; Division of Cardiac Surgery, Yale School of Medicine, New Haven, Conn
| | - Yun Wang
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Conn; Division of Cardiology, Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Shubhadarshini G Pawar
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, Calif
| | - Torsten Vahl
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Tamim Nazif
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Oyere Onuma
- Division of Cardiology, Department of Medicine, Yale University School of Medicine, New Haven, Conn
| | - Celina M Yong
- Division of Cardiology, Department of Medicine, Stanford Medical Center, California and Veterans Affairs Palo Alto Healthcare System, Palo Alto
| | - Rahul Sharma
- Division of Cardiology, Department of Medicine, Stanford Medical Center, California and Veterans Affairs Palo Alto Healthcare System, Palo Alto
| | - Ajay J Kirtane
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - John K Forrest
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT
| | - Isaac George
- Cardiothoracic Surgery, Columbia University Irving Medical Center, New York, NY
| | - Susheel Kodali
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Joanna Chikwe
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, Calif
| | - Arnar Geirsson
- Division of Cardiac Surgery, Yale School of Medicine, New Haven, Conn
| | - Raj Makkar
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, Calif
| | - Martin B Leon
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Harlan M Krumholz
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Conn; Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT; Department of Health Policy and Management, Yale School of Public Health, New Haven, Conn.
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6
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Roberts SH, Kaneko T. Simplest Explanations to a Complex Problem: Does Hospital Volume Explain Variability in TAVR Cost? Ann Thorac Surg 2024; 117:533-534. [PMID: 37142198 DOI: 10.1016/j.athoracsur.2023.04.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 04/23/2023] [Indexed: 05/06/2023]
Affiliation(s)
- Sophia H Roberts
- Division of Cardiothoracic Surgery, Washington University in St Louis, 660 S Euclid Ave, St Louis, MO 63110
| | - Tsuyoshi Kaneko
- Division of Cardiothoracic Surgery, Washington University in St Louis, 660 S Euclid Ave, St Louis, MO 63110.
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van Bakel PAJ, Ahmed Y, Hou H, Sukul D, Likosky DS, van Herwaarden JA, Patel HJ, Thompson MP. Geographic variation in aortic stenosis treatment and outcomes among Medicare beneficiaries in the United States. Catheter Cardiovasc Interv 2024; 103:490-498. [PMID: 38329195 DOI: 10.1002/ccd.30959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 12/05/2023] [Accepted: 01/16/2024] [Indexed: 02/09/2024]
Abstract
BACKGROUND Transcatheter aortic valve replacement (TAVR) has changed the landscape of aortic stenosis (AS) management. AIM To describe and evaluate geographic variation in AS treatment and outcomes among a sample of Medicare beneficiaries. METHODS A retrospective analysis of administrative claims data was conducted on a 20% sample of Medicare fee-for-service beneficiaries aged 65 and older with a diagnosis of AS (2015-2018). Estimates of demographic, comorbidity, and healthcare resources were obtained from Medicare claims and the Dartmouth Atlas of Health Care at the hospital referral region (HRR), which represents regional tertiary medical care markets. Linear regression was used to explain HRR-level variation in rates of surgical aortic valve replacement (SAVR) and TAVR, and 1-year mortality and readmission rates. RESULTS A total of 740,899 beneficiaries with AS were identified with a median prevalence of AS of 39.9 per 1000 Medicare beneficiary years. The average HRR-level rate of SAVR was 26.3 procedures per 1000 beneficiary years and the rate of TAVR was 20.3 procedures per 1000 beneficiary years. HRR-level comorbidities and number of TAVR centers were associated with a lower SAVR rate. Demographics and comorbidities explained most of the variation in HRR-level 1-year mortality (15.2% and 18.8%) and hospitalization rates (20.5% and 16.9%), but over half of the variation remained unexplained. CONCLUSION Wide regional variation in the treatment and outcomes of AS was observed but were largely unexplained by patient factors and healthcare utilization. Understanding the determinants of AS treatment and outcomes can inform population health efforts for these patients.
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Affiliation(s)
- Pieter A J van Bakel
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan, USA
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Yunus Ahmed
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan, USA
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Hechuan Hou
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Devraj Sukul
- Department of Internal Medicine, Division of Cardiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Donald S Likosky
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Joost A van Herwaarden
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Himanshu J Patel
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Michael P Thompson
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan, USA
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan, USA
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David G, Bergman A, Gunnarsson C, Ryan M, Chikermane S, Thompson C, Clancy S. Limited Access to Aortic Valve Procedures in Socioeconomically Disadvantaged Areas. J Am Heart Assoc 2024; 13:e030569. [PMID: 38216519 PMCID: PMC10926797 DOI: 10.1161/jaha.123.030569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 12/01/2023] [Indexed: 01/14/2024]
Abstract
BACKGROUND To explore how differences in local socioeconomic deprivation impact access to aortic valve procedures and the treatment of aortic valve disease, in comparison to other open and minimally invasive surgical procedures. METHODS AND RESULTS Procedure volume data were obtained from the Healthcare Cost and Utilization Project from 18 states from 2016 to 2019 and merged with area deprivation index data, an index of zip code-level socioeconomic distress. We estimate the relationship between local deprivation ranking and differences in volumes of aortic valve replacement, which include transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR), versus coronary artery bypass graft surgery and laparoscopic colectomy (LC). All regressions control for state and year fixed effects and an array of zip code-level characteristics. TAVR procedures have increased over time across all zip codes. The rate of increase is negatively correlated with deprivation ranking, regardless of the higher share of hospitalizations per population in high deprivation areas. Distributional analysis further supports these findings, showing that lower area deprivation index areas account for a disproportionately large share of SAVR, TAVR, and LC procedures in our sample relative to their share of all hospitalizations in our sample. By comparison, the cumulative distribution of coronary artery bypass graft procedures was nearly identical to that of total hospitalizations, suggesting that this procedure is equitably distributed. Regressions show high area deprivation index areas have lower prevalence of SAVR (β=-15.1%, [95% CI, -26.8 to -3.5]), TAVR (β=-9.1%, [95% CI, -18.0 to -0.2]), and LC (β=-19.9%, [95% CI, -35.4 to -4.4]), with no statistical difference in the prevalence of coronary artery bypass graft (β=-2.5%, [95% CI, -12.7 to 7.6]), a widespread and commonly performed procedure. In the population aged ≥80 years, results show high area deprivation index areas have a lower prevalence of TAVR (β=-11.9%, [95% CI, -18.7 to -5.2]) but not SAVR (β=-0.8%, [95% CI, 8.1 to 6.3]), LC (β=-3.5%, [95% CI, -13.4 to -6.4]), or coronary artery bypass graft (β=5.2%, [95% CI, -1.1 to 1.1]). CONCLUSIONS People living in high deprivation areas have less access to life-saving technologies, such as SAVR, and even moreso to device-intensive minimally invasive procedures such as TAVR and LC.
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Affiliation(s)
- Guy David
- Department of Health Care Management, The Wharton SchoolUniversity of PennsylvaniaPhiladelphiaPA
| | - Alon Bergman
- Department of Health Care Management, The Wharton SchoolUniversity of PennsylvaniaPhiladelphiaPA
- Department of Medical Ethics and Health Policy, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
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9
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Nathan AS, Reddy KP, Eberly LA, Fanaroff A, Julien HM, Fiorilli P, Wald J, Mutaawe S, Cevasco M, Bermudez C, Kapur NK, Basir MB, Roswell R, Groeneveld PW, Giri J. Racial, Ethnic, Socioeconomic, and Geographic Inequities in Access to Mechanical Circulatory Support. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2024; 3:101193. [PMID: 39131979 PMCID: PMC11307759 DOI: 10.1016/j.jscai.2023.101193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 09/26/2023] [Accepted: 09/26/2023] [Indexed: 08/13/2024]
Abstract
Background Hospital admissions for cardiogenic shock have increased in the United States. Temporary mechanical circulatory support (tMCS) can be used to acutely stabilize patients. We sought to evaluate the presence of racial, ethnic, and socioeconomic inequities in access to MCS in the United States among patients with cardiogenic shock. Methods Medicare data were used to identify patients with cardiogenic shock admitted to hospitals with advanced tMCS (microaxial left ventricular assist device [mLVAD] or extracorporeal membranous oxygenation [ECMO]) capabilities within the 25 largest core-based statistical areas, all major metropolitan areas. We modeled the association between patient race, ethnicity, and socioeconomic status and use of mLVAD or ECMO. Results After adjusting for age and clinical comorbidities, dual eligibility for Medicaid was associated with a 19.9% (95% CI, 11.5%-27.4%) decrease in odds of receiving mLVAD in a patient with cardiogenic shock (P < .001). After adjusting for age, clinical comorbidities, and dual eligibility for Medicaid, Black race was associated with 36.7% (95% CI, 28.4%-44.2%) lower odds of receiving mLVAD in a patient with cardiogenic shock. Dual eligibility for Medicaid was associated with a 62.0% (95% CI, 60.8%-63.1%) decrease in odds of receiving ECMO in a patient with cardiogenic shock (P < .001). Black race was associated with 36.0% (95% CI, 16.6%-50.9%) lower odds of receiving ECMO in a patient with cardiogenic shock, after adjusting for Medicaid eligibility. Conclusions We identified large and significant racial, ethnic, and socioeconomic inequities in access to mLVAD and ECMO among patients presenting with cardiogenic shock to metropolitan hospitals with active advanced tMCS programs. These findings highlight systematic inequities in access to potentially lifesaving therapies.
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Affiliation(s)
- Ashwin S. Nathan
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, Pennsylvania
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Kriyana P. Reddy
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lauren A. Eberly
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, Pennsylvania
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alexander Fanaroff
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, Pennsylvania
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Howard M. Julien
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, Pennsylvania
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Paul Fiorilli
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, Pennsylvania
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Joyce Wald
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Shafik Mutaawe
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Marisa Cevasco
- Division of Cardiac Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christian Bermudez
- Division of Cardiac Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Navin K. Kapur
- The CardioVascular Center, Tufts Medical Center, Boston, Massachusetts
| | | | - Robert Roswell
- Zucker School of Medicine, Northwell Health, Hofstra University, Hempstead, New York
| | - Peter W. Groeneveld
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jay Giri
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, Pennsylvania
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
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10
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Brlecic PE, Hogan KJ, Treffalls JA, Sylvester CB, Coselli JS, Moon MR, Rosengart TK, Chatterjee S, Ghanta RK. Socioeconomic disparities in procedural choice and outcomes after aortic valve replacement. JTCVS OPEN 2023; 16:139-157. [PMID: 38204692 PMCID: PMC10775113 DOI: 10.1016/j.xjon.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 09/07/2023] [Accepted: 10/04/2023] [Indexed: 01/12/2024]
Abstract
Objective To identify potential socioeconomic disparities in the procedural choice of patients undergoing surgical aortic valve replacement (SAVR) versus transcatheter aortic valve replacement (TAVR) and in readmission outcomes after SAVR or TAVR. Methods The Nationwide Readmissions Database was queried to identify a total of 243,691 patients who underwent isolated SAVR and TAVR between January 2016 and December 2018. Patients were stratified according to a tiered socioeconomic status (SES) metric comprising patient factors including education, literacy, housing, employment, insurance status, and neighborhood median income. Multivariable analyses were used to assess the effect of SES on procedural choice and risk-adjusted readmission outcomes. Results SAVR (41.4%; 100,833 of 243,619) was performed less frequently than TAVR (58.6%; 142,786 of 243,619). Lower SES was more frequent among patients undergoing SAVR (20.2% [20,379 of 100,833] vs 19.4% [27,791 of 142,786]; P < .001). Along with such variables as small hospital size, drug abuse, arrhythmia, and obesity, lower SES was independently associated with SAVR relative to TAVR (adjusted odds ratio [aOR], 1.17; 95% confidence interval [CI], 1.11 to 1.24). After SAVR, but not after TAVR, lower SES was independently associated with increased readmission at 30 days (aOR, 1.19; 95% CI, 1.07-1.32), 90 days (aOR, 1.27; 95% CI, 1.15-1.41), and 1 year (adjusted hazard ratio, 1.19; 95% CI, 1.11 to 1.28; P < .05 for all). Conclusions Our study findings indicate that socioeconomic disparities exist in the procedural choice for patients undergoing AVR. Patients with lower SES had increased odds of undergoing SAVR, as well as increased odds of readmission after SAVR, but not after TAVR, supporting that health inequities exist in the surgical care of socioeconomically disadvantaged patients.
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Affiliation(s)
- Paige E. Brlecic
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Katie J. Hogan
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
- Medical Scientist Training Program, Baylor College of Medicine, Houston, Tex
| | - John A. Treffalls
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
- Long School of Medicine, University of Texas Health San Antonio, San Antonio, Tex
| | - Christopher B. Sylvester
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
- Medical Scientist Training Program, Baylor College of Medicine, Houston, Tex
| | - Joseph S. Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
- Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, Tex
| | - Marc R. Moon
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
- Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, Tex
| | - Todd K. Rosengart
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
- Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, Tex
| | - Subhasis Chatterjee
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
- Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, Tex
| | - Ravi K. Ghanta
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
- Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, Tex
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11
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Preventza O, Akpan-Smart E, Simpson KK, Cornwell LD, Amarasekara H, Green SY, Chatterjee S, LeMaire SA, Coselli JS. The intersection of community socioeconomic factors with gender on outcomes after thoracic aortic surgery. J Thorac Cardiovasc Surg 2023; 166:1572-1582.e10. [PMID: 36396474 DOI: 10.1016/j.jtcvs.2022.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 09/23/2022] [Accepted: 10/06/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE We evaluated the relationship among community socioeconomic factors (poverty, income, and education), gender, and outcomes in patients who underwent ascending aortic, root, and arch surgery. METHODS For 2634 consecutive patients, we associated patients' ZIP codes with community socioeconomic factors. The composite adverse outcome comprised death, persistent neurological injury, and renal failure necessitating dialysis at discharge. Multivariable analysis and Kaplan-Meier survival curves were used. Men and women from the full cohort and from the elective patients were propensity matched. RESULTS Median follow-up was 3.6 years (interquartile range, 1.2-9.3). Men lived in areas characterized by less poverty (P = .03), higher household income (P = .01), and more education (P = .02) than women; likewise, in the elective cohort, all community socioeconomic factors favored men (P ≤ .009). Female gender predicted composite adverse outcome (P = .006). In the propensity-matched women and men (820 pairs), the composite adverse outcome rates were 14.2% and 11%, respectively (P = .06). In 583 propensity-matched pairs of elective patients, men had less composite adverse outcome (P = .02), operative mortality (P = .04), and renal (P = .02) and respiratory failure (P = .0006). The 5- and 10-year survivals for these men and women were 74.2% versus 71.4% and 50.2% versus 48.2%, respectively (P = .06). All community socioeconomic factors in both propensity-matched groups nonsignificantly favored men. CONCLUSIONS This study is among the first to examine the association among community socioeconomic factors, gender, and outcomes in patients who undergo proximal aortic surgery. Female gender predicted a composite adverse outcome. In the elective patients, most adverse outcomes were significantly less in men. In the propensity-matched patients, all community socioeconomic factors favored men, although not significantly. Larger studies with patient-level socioeconomic information are needed.
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Affiliation(s)
- Ourania Preventza
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; The Texas Heart Institute, Houston, Tex; Department of Cardiovascular Surgery, CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Tex; Cardiovascular Research Institute, Baylor College of Medicine, Houston, Tex.
| | | | - Katherine K Simpson
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiothoracic Surgery, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Tex
| | - Lorraine D Cornwell
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiothoracic Surgery, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Tex
| | - Hiruni Amarasekara
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Susan Y Green
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Subhasis Chatterjee
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; The Texas Heart Institute, Houston, Tex; Department of Cardiovascular Surgery, CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Tex
| | - Scott A LeMaire
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; The Texas Heart Institute, Houston, Tex; Department of Cardiovascular Surgery, CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Tex; Cardiovascular Research Institute, Baylor College of Medicine, Houston, Tex
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; The Texas Heart Institute, Houston, Tex; Department of Cardiovascular Surgery, CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Tex; Cardiovascular Research Institute, Baylor College of Medicine, Houston, Tex
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12
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Fanaroff AC, Lopes RD. Standing up for equitable treatment of coronary microvascular dysfunction and myocardial infarction with non-obstructive coronary arteries. Eur J Intern Med 2023; 117:52-54. [PMID: 37758566 DOI: 10.1016/j.ejim.2023.09.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 09/22/2023] [Indexed: 09/29/2023]
Affiliation(s)
- Alexander C Fanaroff
- Penn Cardiovascular Outcomes, Quality and Evaluative Research Center, Leonard Davis Institute, and Cardiovascular Medicine Division, University of Pennsylvania, Philadelphia, PA, USA
| | - Renato D Lopes
- Division of Cardiovascular Medicine and Duke Clinical Research Institute, Duke University, Durham, NC, USA.
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Fath AR, Aglan A, Khurana A, Abuasbeh J, Eldaly AS, Mantha Y, Abraham B, Olagunju A, Prasad A. Transcatheter Aortic Valve Replacement: Variations in Use, Charges, and Geography in the United States. Am J Cardiol 2023; 205:363-368. [PMID: 37647820 DOI: 10.1016/j.amjcard.2023.07.151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 07/21/2023] [Accepted: 07/30/2023] [Indexed: 09/01/2023]
Abstract
The use of transcatheter aortic valve replacement (TAVR) in the United States has been increasing but with variability. We used a 100% sample of Medicare beneficiaries (MBs), from the Centers for Medicare and Medicaid Services database, who underwent TAVR by cardiologists between 2015 and 2019. We stratified data by geographic region, rural/urban areas, and provider's gender. We examined the average number of TAVRs performed per 100,000 MBs, the average number of TAVRs performed per individual cardiologist, and the average submitted charge (ASC) per procedure. The number of TAVR per 100,000 MBs was significantly variable among regions in all years (all P≤0.028), except in 2015 (P=0.103), with the highest rates being in the Northeast and the lowest being in the West. The number of TAVRs per cardiologist was significantly different among regions only in 2019 (P=0.04), with the Northeast showing the highest numbers and the South showing the lowest. The ASC was also significantly variable among regions in all years (all P≤0.01). The highest ASC was in the Midwest for all years, whereas the lowest was in the West in 2015 to 2016 and in the South in 2017 to 2019. In all years, the number of TAVRs per cardiologist was higher in urban areas than in rural areas (all P<0.05); however, rural cardiologists had higher ASCs (all P<0.05). The number of TAVR procedures per cardiologist was not significantly different between male and female cardiologists (all P>0.1). Female cardiologists had a significantly higher ASC only in 2015 (P=0.034). In conclusion, there are variations in TAVR use and charges for MBs according to geographic, urban, and rural regions and the performing cardiologist's gender.
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Affiliation(s)
- Ayman R Fath
- Department of Cardiovascular Diseases, University of Texas Health Science Center, San Antonio, Texas
| | - Amro Aglan
- Department of Internal Medicine, Beth Israel Lahey Health, Boston, Massachusetts
| | - Aditya Khurana
- Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - Jumanah Abuasbeh
- Department of Public Health, University of Arizona, Phoenix, Arizona
| | | | - Yogamaya Mantha
- Department of Cardiovascular Diseases, University of Texas Health Science Center, San Antonio, Texas
| | - Bishoy Abraham
- Department of Cardiovascular Diseases, Mayo Clinic, Phoenix, Arizona
| | | | - Anand Prasad
- Department of Cardiovascular Diseases, University of Texas Health Science Center, San Antonio, Texas.
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Aranda-Michel E, Kilner D, Toma C, Serna-Gallegos D, Yousef S, Brown J, Diaz-Castrillon CE, Makani A, Sultan I. A Readmission Risk Score for Transcatheter Aortic Valve Replacement: An Analysis of 200,000 Patients. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 53:8-12. [PMID: 36907697 DOI: 10.1016/j.carrev.2023.02.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 02/23/2023] [Accepted: 02/23/2023] [Indexed: 03/06/2023]
Abstract
OBJECTIVE The objective of this study was to leverage a national database of TAVR procedures to create a risk model for 30-day readmissions. METHODS The National Readmissions Database was reviewed for all TAVR procedures from 2011 to 2018. Previous ICD coding paradigms created comorbidity and complication variables from the index admission. Univariate analysis included any variables with a P-value of ≤0.2. A bootstrapped mixed-effects logistic regression was run using the hospital ID as a random effect variable. By bootstrapping, a more robust estimate of the variables' effect can be generated, reducing the risk of model overfitting. The odds ratio of variables with a P-value <0.1 was turned into a risk score following the Johnson scoring method. A mixed-effect logistic regression was run using the total risk score, and a calibration plot of the observed to expected readmission was generated. RESULTS A total of 237,507 TAVRs were identified, with an in-hospital mortality of 2.2 %. A total of 17.4 % % of TAVR patients were readmitted within 30 days. The median age was 82 with 46 % of the population being women. The risk score values ranged from -3 to 37 corresponding to a predicted readmission risk between 4.6 % and 80.4 %, respectively. Discharge to a short-term facility and being a resident of the hospital state were the most significant predictors of readmission. The calibration plot shows good agreement between the observed and expected readmission rates with an underestimation at higher probabilities. CONCLUSION The readmission risk model agrees with the observed readmissions throughout the study period. The most significant risk factors were being a resident of the hospital state and discharge to a short-term facility. This suggests that using this risk score in conjunction with enhanced post-operative care in these patients could reduce readmissions and associated hospital costs, improving outcomes.
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Affiliation(s)
- Edgar Aranda-Michel
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, PA, United States of America
| | - Dustin Kilner
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, United States of America
| | - Catalin Toma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, United States of America
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, PA, United States of America; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, United States of America
| | - Sarah Yousef
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, PA, United States of America
| | - James Brown
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, PA, United States of America
| | - Carlos E Diaz-Castrillon
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, PA, United States of America
| | - Amber Makani
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, United States of America
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, PA, United States of America; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, United States of America.
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15
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Al-Taweel O, Gill A, Al-Baghdadi Y, Mohammed S, Ji W, Houshmand N, Al-Tarawneh S, Ahsan C. In-hospital Outcomes and the Impact of Transfer Status in Nonelective vs Elective Transcatheter Aortic Valve Replacement. CJC Open 2023; 5:472-479. [PMID: 37397617 PMCID: PMC10314115 DOI: 10.1016/j.cjco.2023.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 03/06/2023] [Indexed: 07/04/2023] Open
Abstract
Background Nonelective transcatheter aortic valve replacement (TAVR) requires additional research to be fully understood. Methods Using the National Inpatient Sample database (2016-2019), we conducted a retrospective cohort study comparing nonelective vs elective TAVR. The primary outcome of interest was the in-hospital mortality rate among patients undergoing nonelective TAVR, compared to that among patients undergoing elective TAVR. We matched patients in a greedy nearest-neighbor 1:1 model and multivariable logistic regression, which was adjusted for demographics, hospital factors, and comorbidities, and was used to compare mortality in our matched cohort. Results Each cohort had 4389 patients in each cohort. When adjusted for age, race, sex, and comorbidities, nonelective TAVR patients had 1.99 times higher odds of suffering in-hospital mortality compared to elective admissions (adjusted odds ratio 1.99, 95% confidence interval: 1.42-2.81; P < 0.001). When separated by transfer status, nonelective patients admitted as regular hospital admissions or transferred from other acute-care centres also had higher odds of suffering in-hospital mortality compared to elective admissions. Conclusions Our findings illustrate that nonelective TAVR patients are a vulnerable population that require additional medical support in the acute-care setting. As the demand for TAVR increases, further discussions regarding access to healthcare in underserved regions, the national physician shortage, and the future of the TAVR industry are imperative.
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Affiliation(s)
- Omar Al-Taweel
- Department of Cardiology, Kirk Kerkorian School of Medicine at the University of Nevada, Las Vegas, Las Vegas, Nevada, USA
| | - Ahmad Gill
- Department of Internal Medicine, Kirk Kerkorian School of Medicine at the University of Nevada, Las Vegas, Las Vegas, Nevada, USA
| | - Yousif Al-Baghdadi
- Department of Internal Medicine, Kirk Kerkorian School of Medicine at the University of Nevada, Las Vegas, Las Vegas, Nevada, USA
| | - Salman Mohammed
- Department of Internal Medicine, Kirk Kerkorian School of Medicine at the University of Nevada, Las Vegas, Las Vegas, Nevada, USA
| | - Wilbur Ji
- Department of Internal Medicine, Kirk Kerkorian School of Medicine at the University of Nevada, Las Vegas, Las Vegas, Nevada, USA
| | - Nazanin Houshmand
- Department of Internal Medicine, Kirk Kerkorian School of Medicine at the University of Nevada, Las Vegas, Las Vegas, Nevada, USA
| | - Saba Al-Tarawneh
- Department of Internal Medicine, Marshall University School of Medicine, Huntington, West Virginia, USA
| | - Chowdhury Ahsan
- Department of Cardiology, Kirk Kerkorian School of Medicine at the University of Nevada, Las Vegas, Las Vegas, Nevada, USA
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16
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Shen YC, Krumholz HM, Hsia RY. Do PCI Facility Openings and Closures Affect AMI Outcomes Differently in High- vs Average-Capacity Markets? JACC Cardiovasc Interv 2023; 16:1129-1140. [PMID: 37225284 PMCID: PMC10229059 DOI: 10.1016/j.jcin.2023.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 02/09/2023] [Accepted: 02/14/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND Disparities in access to percutaneous coronary intervention (PCI) for patients with acute myocardial infarction may result from openings and closures of PCI-providing hospitals, potentially leading to low hospital PCI volume, which is associated with poor outcomes. OBJECTIVES The authors sought to determine whether openings and closures of PCI hospitals have differentially impacted patient health outcomes in high- vs average-capacity PCI markets. METHODS In this retrospective cohort study, the authors identified PCI hospital availability within a 15-minute driving time of zip code communities. The authors categorized communities by baseline PCI capacity and identified changes in outcomes associated with PCI-providing hospital openings and closures using community fixed-effects regression models. RESULTS From 2006 to 2017, 20% and 16% of patients in average- and high-capacity markets, respectively, experienced a PCI hospital opening within a 15-minute drive. In average-capacity markets, openings were associated with a 2.6 percentage point decrease in admission to a high-volume PCI facility; high-capacity markets saw an 11.6 percentage point decrease. After an opening, patients in average-capacity markets experienced a 5.5% and 7.6% relative increase in likelihood of same-day and in-hospital revascularization, respectively, as well as a 2.5% decrease in mortality. PCI hospital closures were associated with a 10.4% relative increase in admission to high-volume PCI hospitals and a 1.4 percentage point decrease in receipt of same-day PCI. There was no change observed in high-capacity PCI markets. CONCLUSIONS After openings, patients in average-capacity markets derived significant benefits, whereas those in high-capacity markets did not. This suggests that past a certain threshold, facility opening does not improve access and health outcomes.
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Affiliation(s)
- Yu-Chu Shen
- Naval Postgraduate School, Monterey, California, USA; National Bureau of Economic Research, Cambridge Massachusetts, USA
| | - Harlan M Krumholz
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA; Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut, USA; Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut, USA
| | - Renee Y Hsia
- Department of Emergency Medicine, University of California-San Francisco, San Francisco, California, USA; Philip R. Lee Institute for Health Policy Studies, University of California-San Francisco, San Francisco, California, USA.
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Nelson AJ, Wegermann ZK, Gallup D, O’Brien S, Kosinski AS, Thourani VH, Kumbhani DJ, Kirtane A, Allen J, Carroll JD, Shahian DM, Desai ND, Brindis RG, Peterson ED, Cohen DJ, Vemulapalli S. Modeling the Association of Volume vs Composite Outcome Thresholds With Outcomes and Access to Transcatheter Aortic Valve Implantation in the US. JAMA Cardiol 2023; 8:492-502. [PMID: 37017940 PMCID: PMC10077135 DOI: 10.1001/jamacardio.2023.0477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 02/13/2023] [Indexed: 04/06/2023]
Abstract
Importance Professional societies and the Centers for Medicare & Medicaid Services suggest volume thresholds to ensure quality in transcatheter aortic valve implantation (TAVI). Objective To model the association of volume thresholds vs spoke-and-hub implementation of outcome thresholds with TAVI outcomes and geographic access. Design, Setting, and Participants This cohort study included patients who enrolled in the US Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy registry. Site volume and outcomes were determined from a baseline cohort of adults undergoing TAVI between July 1, 2017, and June 30, 2020. Exposures Within each hospital referral region, TAVI sites were categorized by volume (<50 or ≥50 TAVIs per year) and separately by risk-adjusted outcome on the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy 30-day TAVI composite during the baseline period (July 2017 to June 2020). Outcomes of patients undergoing TAVIs from July 1, 2020, to March 31, 2022, were then modeled as though the patients had been treated at (1) the nearest higher volume (≥50 TAVIs per year) or (2) the best outcome site within the hospital referral region. Main Outcomes and Measures The primary outcome was the absolute difference in events between the adjusted observed and modeled 30-day composite of death, stroke, major bleeding, stage III acute kidney injury, and paravalvular leak. Data are presented as the number of events reduced under the above scenarios with 95% bayesian credible intervals (CrIs) and median (IQR) driving distance. Results The overall cohort included 166 248 patients with a mean (SD) age of 79.5 (8.6) years; 74 699 (47.3%) were female and 6657 (4.2%) were Black; 158 025 (95%) were treated in higher-volume sites (≥50 TAVIs) and 75 088 (45%) were treated in best-outcome sites. Modeling a volume threshold, there was no significant reduction in estimated adverse events (-34; 95% CrI, -75 to 8), while the median (IQR) driving time from the existing site to the alternate site was 22 (15-66) minutes. Transitioning care to the best outcome site in a hospital referral region resulted in an estimated 1261 fewer adverse outcomes (95% CrI, 1013-1500), while the median (IQR) driving time from the original site to the best site was 23 (15-41) minutes. Directionally similar findings were observed for Black individuals, Hispanic individuals, and individuals from rural areas. Conclusions and Relevance In this study, compared with the current system of care, a modeled outcome-based spoke-and-hub paradigm of TAVI care improved national outcomes to a greater extent than a simulated volume threshold, at the cost of increased driving time. To improve quality while maintaining geographic access, efforts should focus on reducing site variation in outcomes.
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Affiliation(s)
- Adam J. Nelson
- Duke Clinical Research Institute, Durham, North Carolina
| | | | - Dianne Gallup
- Duke Clinical Research Institute, Durham, North Carolina
| | - Sean O’Brien
- Duke Clinical Research Institute, Durham, North Carolina
| | | | | | - Dharam J. Kumbhani
- Division of Cardiology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Ajay Kirtane
- Department of Medicine, Columbia University, New York, New York
- Cardiovascular Research Foundation, New York, New York
- Associate Editor, JAMA Cardiology
| | - Joseph Allen
- American College of Cardiology, Gaithersburg, Maryland
| | - John D. Carroll
- Division of Cardiology, Department of Medicine, University of Colorado, Aurora
| | - David M. Shahian
- Division of Cardiac Surgery and Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Nimesh D. Desai
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia
| | - Ralph G. Brindis
- Philip R. Lee Institute of Health Policy Studies, University of California, San Francisco
| | - Eric D. Peterson
- Division of Cardiology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas
| | - David J. Cohen
- Cardiovascular Research Foundation, New York, New York
- St Francis Hospital, Roslyn, New York
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18
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Iyengar A, Patrick WL, Helmers MR, Kelly JJ, Han J, Williams ML, Mackay EJ, Desai ND, Cevasco M. Neighborhood Socioeconomic Status Independently Predicts Outcomes After Mitral Valve Surgery. Ann Thorac Surg 2023; 115:940-947. [PMID: 36623633 DOI: 10.1016/j.athoracsur.2023.01.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 12/08/2022] [Accepted: 01/03/2023] [Indexed: 01/08/2023]
Abstract
BACKGROUND Socioeconomic status has increasingly recognized influence on outcomes after cardiac surgery. However, singular metrics fail to fully capture the socioeconomic context within which patients live, which vary greatly between neighborhoods. We sought to explore the impact of neighborhood-level socioeconomic status on patients undergoing mitral valve surgery in the United States. METHODS Adults undergoing first-time, isolated mitral valve surgery were queried from The Society of Thoracic Surgeons Adult Cardiac Surgery Database between 2012 and 2018. Socioeconomic status was quantified using the Area Deprivation Index, a weighted composite including average housing prices, household incomes, education, and employment levels. The associations between regional deprivation, access to mitral surgery, valve repair rates, and outcomes were evaluated using logistic regression. RESULTS Among 137,100 patients included, patients with socioeconomic deprivation had fewer elective presentations, more comorbidity burden, and more urgent/emergent surgery. Patients from less disadvantaged areas received operations from higher volume surgeons and had higher repair rates (highest vs lowest quintile: 72% vs 51%, P < .001, more minimally-invasive approach (33% vs 20%, P < .001), lower composite complication rate (42% vs 50%, P < .001), and lower 30-day mortality (1.8% vs 3.9%, P < .001). After hierarchical multivariable adjustment, the Area Deprivation Index significantly predicted 30-day mortality and repair rate (P < .001). CONCLUSIONS In a risk-adjusted national analysis of mitral surgery, patients from more deprived areas were less likely to undergo mitral repair and more likely to have complications. Further work at targeting neighborhood-level disparity is important to improving mitral surgical outcomes in the United States.
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Affiliation(s)
- Amit Iyengar
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - William L Patrick
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mark R Helmers
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - John J Kelly
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jason Han
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Matthew L Williams
- Division of Cardiovascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Emily J Mackay
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nimesh D Desai
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Marisa Cevasco
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
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19
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Reddy KP, Eberly LA, Halaby R, Julien H, Khatana SAM, Dayoub EJ, Coylewright M, Alkhouli M, Fiorilli PN, Kobayashi TJ, Goldberg DM, Santangeli P, Herrmann HC, Giri J, Groeneveld PW, Fanaroff AC, Nathan AS. Racial, Ethnic, and Socioeconomic Inequities in Access to Left Atrial Appendage Occlusion. J Am Heart Assoc 2023; 12:e028032. [PMID: 36802837 PMCID: PMC10111439 DOI: 10.1161/jaha.122.028032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 11/14/2022] [Indexed: 02/23/2023]
Abstract
Background Inequitable access to high-technology therapeutics may perpetuate inequities in care. We examined the characteristics of US hospitals that did and did not establish left atrial appendage occlusion (LAAO) programs, the patient populations those hospitals served, and the associations between zip code-level racial, ethnic, and socioeconomic composition and rates of LAAO among Medicare beneficiaries living within large metropolitan areas with LAAO programs. Methods and Results We conducted cross-sectional analyses of Medicare fee-for-service claims for beneficiaries aged 66 years or older between 2016 and 2019. We identified hospitals establishing LAAO programs during the study period. We used generalized linear mixed models to measure the association between zip code-level racial, ethnic, and socioeconomic composition and age-adjusted rates of LAAO in the most populous 25 metropolitan areas with LAAO sites. During the study period, 507 candidate hospitals started LAAO programs, and 745 candidate hospitals did not. Most new LAAO programs opened in metropolitan areas (97.4%). Compared with non-LAAO centers, LAAO centers treated patients with higher median household incomes (difference of $913 [95% CI, $197-$1629], P=0.01). Zip code-level rates of LAAO procedures per 100 000 Medicare beneficiaries in large metropolitan areas were 0.34% (95% CI, 0.33%-0.35%) lower for each $1000 zip code-level decrease in median household income. After adjustment for socioeconomic markers, age, and clinical comorbidities, LAAO rates were lower in zip codes with higher proportions of Black or Hispanic patients. Conclusions Growth in LAAO programs in the United States had been concentrated in metropolitan areas. LAAO centers treated wealthier patient populations in hospitals without LAAO programs. Within major metropolitan areas with LAAO programs, zip codes with higher proportions of Black and Hispanic patients and more patients experiencing socioeconomic disadvantage had lower age-adjusted rates of LAAO. Thus, geographic proximity alone may not ensure equitable access to LAAO. Unequal access to LAAO may reflect disparities in referral patterns, rates of diagnosis, and preferences for using novel therapies experienced by racial and ethnic minority groups and patients experiencing socioeconomic disadvantage.
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Affiliation(s)
- Kriyana P. Reddy
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
| | - Lauren A. Eberly
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Division of CardiologyHospital of the University of PennsylvaniaPhiladelphiaPA
- Leonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphiaPA
| | - Rim Halaby
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Division of CardiologyHospital of the University of PennsylvaniaPhiladelphiaPA
| | - Howard Julien
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Division of CardiologyHospital of the University of PennsylvaniaPhiladelphiaPA
- Leonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphiaPA
- Corporal Michael J. Crescenz VA Medical CenterPhiladelphiaPA
| | - Sameed Ahmed M. Khatana
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Division of CardiologyHospital of the University of PennsylvaniaPhiladelphiaPA
- Corporal Michael J. Crescenz VA Medical CenterPhiladelphiaPA
| | - Elias J. Dayoub
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Division of CardiologyHospital of the University of PennsylvaniaPhiladelphiaPA
- Leonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphiaPA
| | | | | | - Paul N. Fiorilli
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Division of CardiologyHospital of the University of PennsylvaniaPhiladelphiaPA
- Leonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphiaPA
- Corporal Michael J. Crescenz VA Medical CenterPhiladelphiaPA
| | - Taisei J. Kobayashi
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Division of CardiologyHospital of the University of PennsylvaniaPhiladelphiaPA
- Leonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphiaPA
- Corporal Michael J. Crescenz VA Medical CenterPhiladelphiaPA
| | | | - Pasquale Santangeli
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Division of CardiologyHospital of the University of PennsylvaniaPhiladelphiaPA
| | - Howard C. Herrmann
- Division of CardiologyHospital of the University of PennsylvaniaPhiladelphiaPA
| | - Jay Giri
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Division of CardiologyHospital of the University of PennsylvaniaPhiladelphiaPA
- Leonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphiaPA
- Corporal Michael J. Crescenz VA Medical CenterPhiladelphiaPA
| | - Peter W. Groeneveld
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Leonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphiaPA
- Corporal Michael J. Crescenz VA Medical CenterPhiladelphiaPA
- Division of General Internal Medicine, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
| | - Alexander C. Fanaroff
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Division of CardiologyHospital of the University of PennsylvaniaPhiladelphiaPA
- Leonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphiaPA
| | - Ashwin S. Nathan
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Division of CardiologyHospital of the University of PennsylvaniaPhiladelphiaPA
- Leonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphiaPA
- Corporal Michael J. Crescenz VA Medical CenterPhiladelphiaPA
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20
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Nathan AS, Reddy KP, Yang L, Eberly LA, Dayoub EJ, Khatana SAM, Julien HM, Desai ND, Szeto WY, Herrmann HC, Kobayashi TJ, Fiorilli P, Batchelor WB, Mehran R, Alkhouli MA, Giri J, Groeneveld PW, Fanaroff AC. Characteristics of Clinical Trial Sites for Novel Transcatheter Mitral and Tricuspid Valvular Therapies. JAMA Cardiol 2023; 8:120-128. [PMID: 36477493 PMCID: PMC9856899 DOI: 10.1001/jamacardio.2022.4457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance Racial and ethnic minority and socioeconomically disadvantaged patients have been underrepresented in randomized clinical trials. Efforts have focused on enhancing inclusion of minority groups at sites participating at clinical trials; however, there may be differences in the patient populations of the sites that participate in clinical trials. Objective To identify any differences in the racial, ethnic, and socioeconomic composition of patient populations among candidate sites in the US that did vs did not participate in trials for novel transcatheter therapies. Design, Setting, and Participants This cross-sectional analysis used Medicare Provider Claims from 2019 for patients admitted to hospitals in the US. All clinical trials for transcatheter mitral and tricuspid valve therapies and the hospitals participating in each of the trials were identified using ClinicalTrials.gov. Hospitals with active cardiac surgical programs that did not participate in the trials were also identified. Data analysis was performed between July 2021 and July 2022. Exposures Multivariable linear regression models were used to identify differences in racial, ethnic, and socioeconomic characteristics among patients undergoing cardiac surgery or transcatheter aortic valve replacement at trial vs nontrial hospitals. Main Outcome and Measures The main outcome of the study was participation in a clinical trial for novel transcatheter mitral or tricuspid valve therapies. Results A total of 1050 hospitals with cardiac surgery programs were identified, of which 121 (11.5%) participated in trials for transcatheter mitral or tricuspid therapies. Patients treated in trial hospitals had a higher median zip code-based household income (difference of $5261; 95% CI, $2986-$7537), a lower Distressed Communities Index score (difference of 5.37; 95% CI, 2.59-8.15), and no significant difference in the proportion of patients dual eligible for Medicaid (difference of 0.86; 95% CI, -2.38 to 0.66). After adjusting for each of the socioeconomic indicators separately, there was less than 1% difference in the proportion of Black and Hispanic patients cared for at hospitals participating vs not participating in clinical trials. Conclusions and Relevance In this cohort study among candidate hospitals for clinical trials for transcatheter mitral or tricuspid valve therapies, trial hospitals took care of a more socioeconomically advantaged population than nontrial hospitals, with a similar proportion of Black and Hispanic patients. These data suggest that site selection efforts may improve enrollment of socioeconomically disadvantaged patients but may not improve the enrollment of Black and Hispanic patients.
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Affiliation(s)
- Ashwin S Nathan
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia.,Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Kriyana P Reddy
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia
| | - Lin Yang
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Lauren A Eberly
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia.,Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Elias J Dayoub
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia.,Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Sameed A M Khatana
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia.,Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Howard M Julien
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia.,Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Nimesh D Desai
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia.,Division of Cardiac Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Wilson Y Szeto
- Division of Cardiac Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Howard C Herrmann
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia
| | - Taisei J Kobayashi
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia.,Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Paul Fiorilli
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | | | - Roxana Mehran
- Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Jay Giri
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia.,Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Peter W Groeneveld
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania.,Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Alexander C Fanaroff
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia.,Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
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21
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Relationship of Neighbourhood Social Deprivation and Ethnicity on Access to Transcatheter and Surgical Aortic Valve Replacement: A Population-Level Study. Can J Cardiol 2023; 39:22-31. [PMID: 36228886 DOI: 10.1016/j.cjca.2022.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 09/19/2022] [Accepted: 10/03/2022] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Wide geographic variation in access to transcatheter (TAVR) and surgical (SAVR) aortic valve replacement exists, but the impact of socioethnic factors on the geographic variation of AS management in Ontario, Canada, is unknown. METHODS Neighbourhood rates of AS admissions, as a proxy for AS burden, and downstream TAVR and SAVR referrals and procedures were estimated for the 76 subregions in Ontario. To determine if the socioethnic geographic variations in referrals and procedures were concordant or discordant with AS burden, we calculated Pearson correlation coefficients to determine the relationship between AS burden and each of TAVR referrals, TAVR procedures, SAVR referrals, or SAVR procedures. We developed generalised linear models to determine the association between social deprivation indices captured in the Ontario Marginalization index and the rates of AS burden as well as TAVR/SAVR referral and procedures. RESULTS There was wide geographic variation that was concordant between AS burden and the referral and procedure rates for TAVR and SAVR (correlation coefficients 0.86-0.96). Increased dependency was associated with higher rates of both TAVR/SAVR referrals and procedures (rate ratios 1.63-2.22). Neighbourhoods with a higher concentration of ethnic minorities were associated with lower AS burden as well as lower rates of both SAVR and TAVR referrals and procedures (rate ratios 0.57-0.85). CONCLUSIONS An important ethnic gradient exists in AS burden and in both referral and completion of TAVR and SAVR in Ontario. Further research is necessary to understand if this gradient is appropriate or requires mitigation.
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22
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Bullock-Palmer RP, Bravo-Jaimes K, Mamas MA, Grines CL. Socioeconomic Factors and their Impact on Access and Use of Coronary and Structural Interventions. Eur Cardiol 2022; 17:e19. [PMID: 36643068 PMCID: PMC9820075 DOI: 10.15420/ecr.2022.23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 06/28/2022] [Indexed: 01/18/2023] Open
Abstract
In the past few decades, the accelerated improvement in technology has allowed the development of new and effective coronary and structural heart disease interventions. There has been inequitable patient access to these advanced therapies and significant disparities have affected patients from low socioeconomic positions. In the US, these disparities mostly affect women, black and hispanic communities who are overrepresented in low socioeconomic. Other adverse social determinants of health influenced by structural racism have also contributed to these disparities. In this article, we review the literature on disparities in access and use of coronary and structural interventions; delineate the possible reasons underlying these disparities; and highlight potential solutions at the government, healthcare system, community and individual levels.
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Affiliation(s)
| | - Katia Bravo-Jaimes
- Division of Cardiology, Department of Internal Medicine, Ahmanson/UCLA Adult Congenital Heart Disease Center, University of CaliforniaLos Angeles, CA, US
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele UniversityKeele, UK
| | - Cindy L Grines
- Division of Cardiology, Department of Internal Medicine, Northside Cardiovascular Institute, Northside HospitalAtlanta, GA, US
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23
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Fanaroff AC, Nathan AS. Percutaneous Coronary Intervention in Acute Coronary Syndrome and Cardiogenic Shock: Ensuring Access While Maintaining Quality. JACC Cardiovasc Interv 2022; 15:887-889. [PMID: 35450688 DOI: 10.1016/j.jcin.2022.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 02/01/2022] [Indexed: 10/18/2022]
Affiliation(s)
- Alexander C Fanaroff
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, Pennsylvania USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania USA.
| | - Ashwin S Nathan
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, Pennsylvania USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania USA; Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
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24
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Amponsah DK, Crousillat DR, Elmariah S. Racial and Ethnic Disparities in the Treatment of Aortic Stenosis: Current Challenges and Future Strategies for Achieving Equity in Care. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2022. [DOI: 10.1007/s11936-022-00963-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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25
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Giri J, Fiorilli PN. Did the COVID-19 Pandemic Just Turn TAVR Into an Outpatient Procedure? JACC Cardiovasc Interv 2022; 15:599-602. [PMID: 35331451 PMCID: PMC10042628 DOI: 10.1016/j.jcin.2022.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 02/01/2022] [Indexed: 12/21/2022]
Affiliation(s)
- Jay Giri
- Department of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Center for Cardiovascular Outcomes, Quality, and Evaluative Research, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Paul N Fiorilli
- Department of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Center for Cardiovascular Outcomes, Quality, and Evaluative Research, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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26
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Reddy KP, Groeneveld PW, Giri J, Fanaroff AC, Nathan AS. Economic Considerations in Access to Transcatheter Aortic Valve Replacement. Circ Cardiovasc Interv 2022; 15:e011489. [PMID: 35021854 DOI: 10.1161/circinterventions.121.011489] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Transcatheter aortic valve replacement (TAVR) has revolutionized the treatment of aortic stenosis, with the number of procedures and sites offering the procedure steadily rising over the past decade in the United States. Despite this, growth into certain markets has been limited as hospitals have to balance high TAVR costs with the ability to offer a complete array of state-of-the-art therapies for aortic stenosis. This trade-off often results in decreased access to TAVR services by patients cared for in hospitals that cannot afford these services or have difficulty meeting procedural requirements, recruiting skilled physicians, and initiating and then maintaining a functioning TAVR program. The lack of access is more common among patients of color or those who are socioeconomically disadvantaged. The purpose of this review is to describe the hospital-level economic considerations of TAVR in the United States and the resulting effects on geographic, racial, ethnic, and socioeconomic access for Americans.
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Affiliation(s)
- Kriyana P Reddy
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center (K.P.R., P.W.G., J.G., A.C.F., A.S.N.), University of Pennsylvania, Philadelphia
| | - Peter W Groeneveld
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center (K.P.R., P.W.G., J.G., A.C.F., A.S.N.), University of Pennsylvania, Philadelphia.,Leonard Davis Institute of Health Economics (P.W.G., J.G., A.C.F., A.S.N.), University of Pennsylvania, Philadelphia.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA (P.W.G., J.G., A.S.N.)
| | - Jay Giri
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center (K.P.R., P.W.G., J.G., A.C.F., A.S.N.), University of Pennsylvania, Philadelphia.,Leonard Davis Institute of Health Economics (P.W.G., J.G., A.C.F., A.S.N.), University of Pennsylvania, Philadelphia.,Cardiovascular Division (J.G., A.C.F., A.S.N.), Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Alexander C Fanaroff
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center (K.P.R., P.W.G., J.G., A.C.F., A.S.N.), University of Pennsylvania, Philadelphia.,Leonard Davis Institute of Health Economics (P.W.G., J.G., A.C.F., A.S.N.), University of Pennsylvania, Philadelphia.,Cardiovascular Division (J.G., A.C.F., A.S.N.), Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Ashwin S Nathan
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center (K.P.R., P.W.G., J.G., A.C.F., A.S.N.), University of Pennsylvania, Philadelphia.,Leonard Davis Institute of Health Economics (P.W.G., J.G., A.C.F., A.S.N.), University of Pennsylvania, Philadelphia.,Cardiovascular Division (J.G., A.C.F., A.S.N.), Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA (P.W.G., J.G., A.S.N.)
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