Racial, Ethnic, and Socioeconomic Inequities in Access to Left Atrial Appendage Occlusion

Inter- and Intrahospital Price Variation for Common Cardiovascular Admission Diagnoses, Diagnostic Tests, and Therapeutic Procedures

BACKGROUND

The 2021 Price Transparency Rule was implemented to increase market competition, facilitate price shopping, and reduce prices and health care costs. We sought to measure inter- and intrahospital variation in prices, measure price variation across payer types, and identify hospital characteristics associated with increased commercial prices for 16 common cardiovascular admission diagnoses, diagnostic tests, and therapeutic procedures.

METHODS AND RESULTS

Prices were obtained from Turquoise Health, a platform that aggregates hospital prices from publicly available machine-readable files, for each diagnosis, test, and procedure based on Current Procedural Terminology (CPT) and Medicare Severity Diagnosis Related Group (DRG) codes. Hospital characteristics were identified using Dartmouth Atlas data. Inter- and intrahospital price variations were measured using ratios. Multivariate linear mixed-effects models were fit to determine the association between hospital characteristics and hospital-level median commercial negotiated rates. We evaluated 1 020 349 unique rates across all diagnoses, tests, and procedures. The median (interquartile range) ratio of maximum to minimum commercial prices within hospitals ranged from 1.71 (1.14-2.53) for syncope and collapse to 3.1 (2.06-4.58) for cardiac valve surgery. Many hospital referral regions had 90th percentile commercial prices 2 to 3 times larger than 10th percentile commercial prices. Nonprofit status and high hospital market concentration were associated with increased commercial prices across all diagnoses, tests, and procedures.

CONCLUSIONS

There is significant price variation for common cardiovascular admission diagnoses, tests, and procedures across and within hospitals as well as across payer types. Increased hospital market concentration is associated with increased commercial prices, so efforts to improve market competition alongside improving transparency compliance are warranted.

Impact of Social Determinants of Health on Cardiovascular Disease

An increasing number of studies have shown the impact of social determinants of health (SDoHs) on different cardiovascular outcomes. SDoHs influence the regional incidence of heart failure, heart failure outcomes, and heart failure readmission rates; can prevent use of advanced heart failure therapies in minorities with an indication for their use; can influence the incidence of coronary artery disease and peripheral artery disease outcomes; and can also prevent providing equal quality of care to all patients with myocardial infarction. In the setting of arrhythmias, specific SDoHs can increase the incidence of atrial fibrillation and adversely affect major outcomes in these patients. In congenital heart diseases, SDoHs can affect major outcomes, as well. In conclusion, SDoHs significantly impact cardiovascular morbidity and death and specific outcomes of patients with cardiovascular disease. Policy measures that aim to improve those SDoHs that negatively affect health outcomes hold promise for improving cardiovascular outcomes at individual and population levels.

Care for Atrial Fibrillation and Outcomes in Rural Versus Urban Communities in the United States: A Systematic and Narrative Review

Atrial fibrillation (AF) is the most common sustained arrhythmia and associated with increased morbidity and mortality. Differences have been identified between medical care delivered in urban and rural settings, and rurality-based disparities may exist in AF care. We performed a systematic review investigating the effect of rurality on AF care and outcomes in the United States. PubMed was queried for entries on AF and rurality: ("atrial fibrillation" OR "atrial flutter") AND ("rural" OR "urban" OR "rurality" OR "metro" OR "metropolitan") AND ("united states" OR "US" OR "U.S.") published up to September 24, 2023. Anticoagulation, rhythm control, settings of care, outcomes, and all-cause mortality were reviewed in relevant studies. The search identified 395 total articles. After screening, 14 relevant articles were included in the review. These studies ranged from 1993 to 2020 and analyzed approximately 41.7 million AF patient encounters. The use of catheter ablation for AF per electrophysiologist was similar across the rural-urban spectrum. Patients with AF and rural residence were less likely to receive a direct oral anticoagulant and more likely to remain on warfarin (relative risk, 0.90 [95% CI, 0.88-0.92]). Patients in rural communities were less likely to receive non-emergent AF care (odds ratio [OR], 0.96 [95% CI, 0.93-0.98]). In-hospital mortality for patients with AF admitted to rural hospitals was higher than urban hospitals (OR, 1.19 [95% CI, 1.01-1.39)]. Measurable differences exist in both treatments and outcomes of patients with AF between rural and urban settings in the United States. These differences should inform future investigations and strategies to improve health in people with AF.

Racial and Ethnic Disparities in the Use and Outcomes With WATCHMAN FLX: A SURPASS Analysis of the NCDR Left Atrial Appendage Occlusion Registry

BACKGROUND

Left atrial appendage occlusion (LAAO) is increasingly used as an alternative to oral anticoagulation for stroke prevention in select patients with atrial fibrillation. Data on outcomes in racial and ethnic minority individuals are limited. This analysis assessed differences in the use and outcomes of LAAO by race and ethnicity in a large national registry.

METHODS AND RESULTS

This analysis acquired data on patients who underwent WATCHMAN FLX implantation from the retrospective NCDR (National Cardiovascular Data Registry) LAAO registry through September 2022. All patients with an attempted WATCHMAN FLX implantation and known race and ethnicity were included. Baseline characteristics and 1-year event rates were compared. A total of 97 185 patients were analyzed; 87 339 were White individuals (90%), 3750 Black individuals (3.9%), and 2866 Hispanic individuals (Hispanic/Latinx), 2.9%). Black and Hispanic patients were younger, with a higher incidence of prior stroke and significant bleeding compared with White patients. Black and Hispanic patients were treated with LAAO in smaller numbers relative to their proportion of the US population. Rates of procedural success were similar between groups. Though direct oral anticoagulants were prescribed in most patients across the groups, dual and single antiplatelet therapy were prescribed more often in Black patients. Black patients had significantly higher rates of 1-year death and bleeding compared with White and Hispanic patients.

CONCLUSIONS

Patients from racial and ethnic minority groups comprise a disproportionately small fraction of all patients who undergo LAAO. Black and Hispanic patients were younger but had significantly higher comorbidities compared with White patients. Procedural success was similar among the groups, but Black patients experienced higher rates of death and bleeding at 1 year.

Long-Term Clinical Outcomes Following the WATCHMAN Device Use in Medicare Beneficiaries

BACKGROUND

Long-term outcomes following left atrial appendage occlusion outside clinical trials and small registries are largely unknown. Collecting these data was a condition of US market authorization of the WATCHMAN device. The aim of this analysis was to evaluate the rates of stroke, bleeding, and death among Medicare beneficiaries following left atrial appendage occlusion implantation during initial commercial availability of the WATCHMAN left atrial appendage occlusion device overall and in important subgroups.

METHODS

All Medicare fee-for-service beneficiaries ≥65 years of age who underwent left atrial appendage occlusion from April 1, 2016, to August 31, 2020, were included based on the International Classification of Diseases, Tenth Revision, and Current Procedural Terminology codes. Over a 5-year follow-up period, the cumulative incidence over time of mortality, ischemic stroke, and major bleeding were calculated using the International Classification of Diseases, Tenth Revision, diagnosis codes for the full study cohort and within important prespecified subgroups.

RESULTS

WATCHMAN recipients (n=48 763) were a median of 77 (interquartile range, 72-82) years of age, 42% female, and mostly White (93%). The median CHA2DS2VASc score was 4 (interquartile range, 3-5) with prior major bleeding in 42% and prior stroke in 12%. At 5 years, death occurred in 44%, bleeding in 15% (with higher risk early following implantation), and ischemic stroke in 7%. Each of these end points was more common with greater baseline age. Male patients had greater 5-year mortality than female patients (46.9% versus 40.6%), but there was no difference between sexes in the rates of ischemic stroke (6.6% versus 7.5%) or major bleeding (14.9% for both). WATCHMAN recipients with prior ischemic stroke or a major bleeding event were older and frailer; these groups had higher rates of ischemic stroke, major bleeding, and death.

CONCLUSIONS

Compared with patients enrolled in the pivotal clinical trials, Medicare beneficiaries undergoing WATCHMAN implantation were older, more female, and had more comorbid conditions. Substantial long-term mortality and major bleeding following WATCHMAN reflect the high-risk nature of the patient population, while the ischemic stroke rate was relatively low (<1.5% per year).

Social drivers in atrial fibrillation occurrence, screening, treatment, and outcomes: systematic-narrative hybrid review

The importance of social drivers of health (SDOH) in the occurrence, detection, treatment, and outcome of atrial fibrillation (AF) has attracted increasing attention. Addressing SDOH factors may suggest opportunities to prevent AF and its complications. We aimed to conduct a structured narrative review and summarize current knowledge on the association between race and ethnicity, SDOH, including rural vs. urban habitation, education, income, and neighbourhood, and the risk of AF, its management, and complications. We identified 537 references in PubMed and 473 references in Embase. After removal of duplicates, we screened the abstracts of 975 references, resulting in 113 references that were examined for eligibility. Subsequently, 34 references were excluded leaving 79 references for the review. Evidence of a social gradient in AF incidence and prevelance were conflicting. However, we found substantial evidence indicating social inequities in the detection of AF, access to treatment, and outcomes such as healthcare utilization, bleeding, heart failure, stroke, dementia, work disability, and death. Inequities are reported across various health care systems and constitute a global problem affecting several continents, although data from Africa and South America are lacking. Given the documented social inequities in AF detection, management, and outcomes, there is an urgent need for healthcare systems, policymakers, and society to identify and implement effective interventions that can reduce inequities and improve outcomes in individuals with AF.

Patient Characteristics Associated With Using Transcatheter Left Atrial Appendage Occlusion Versus Oral Anticoagulants for Atrial Fibrillation

BACKGROUND

Transcatheter left atrial appendage occlusion (LAAO) is an alternative to oral anticoagulants (OACs) for stroke prevention in patients with atrial fibrillation, but the predictors of LAAO use in routine care are unclear. We aimed to assess the utilization trends of LAAO and compare the change in characteristics of LAAO users versus OACs since its marketing.

METHODS

Using the US Medicare claims database (March 15, 2015, to December 31, 2020), we identified patients with atrial fibrillation, ≥65 years, and CHA2DS2-VASc score ≥2 (men) or ≥3 (women), with either first implantation of an LAAO device or initiation of OACs, including apixaban, dabigatran, rivaroxaban, edoxaban, or warfarin. Patient characteristics, measured 365 days before the first LAAO or OAC use date, were compared using logistic regression.

RESULTS

There were 30 058 LAAO recipients (mean age, 77.74 years; female, 42.1%) and 792 600 OAC initiators (mean age, 78.48; female, 53.3%). In 2020, patients had higher odds of initiating LAAO use than in 2015 (0.52 versus 9.32%; adjusted odds ratio [aOR], 13.64 [95% CI, 12.56-14.81]). Old age (ie, >85 versus 65-75 years; aOR, 0.84 [95% CI, 0.80-0.88]), female sex (aOR, 0.74 [95% CI, 0.71-0.76]), Black race (aOR, 0.63 [95% CI, 0.58-0.68]) versus White race, and Medicaid eligibility (aOR, 0.61 [95% CI, 0.58-0.64]) were associated with lower odds of receiving LAAO. Among clinical characteristics, frailty, cancer, fractures, and venous thromboembolism were associated with lower odds of LAAO use, while history of intracranial and extracranial bleeding, coagulopathy, and falls were associated with higher odds of receiving LAAO.

CONCLUSIONS

Among patients with atrial fibrillation receiving stroke-preventive therapy, LAAO use increased rapidly from 2015 to 2020 and was positively associated with the risk factors for OAC complications but negatively associated with old age, advanced frailty, and cancer. Black race and female sex were associated with a lower likelihood of receiving LAAO.

Temporal Changes in Racial and Ethnic Disparities in the Utilization of Left Atrial Appendage Occlusion in the United States

Racial and ethnic disparities in the access to left atrial appendage occlusion (LAAO) have been previously described. However, it remains unclear if there have been any changes in these disparities over the years and if the disparities include other racial and ethnic groups not previously studied. We aimed to determine the temporal evolution of the racial and ethnic disparities in the utilization of LAAO from 2016 to 2019. We conducted a retrospective cohort study using the National Inpatient Sample from 2016 to 2019. International Classification of Diseases, 10th edition codes were used to identify all adult admissions with atrial fibrillation (AF) and those who underwent LAAO. The sample was divided into Asian American and Pacific Islander, Black, Hispanic, White, and other races/ethnicities. Our primary outcome was the utilization of LAAO in patients admitted with a diagnosis of AF. The Cochran-Armitage test was conducted to evaluate the yearly trend in LAAO utilization stratified by race/ethnicity. Multivariable regression analysis was conducted to assess the association of race/ethnicity with multiple end points. A total of 59,415 patients underwent LAAO. The highest yearly increase in LAAO utilization was seen in White patients (trend: 0.16%, p <0.001). Furthermore, compared with White patients, the yearly increase in LAAO utilization was lower in all other racial/ethnic groups. Black patients had the lowest odds of who underwent LAAO (odds ratio = 0.45, 95% confidence interval 0.40 to 0.50, p <0.001). In conclusion, significant gaps exist in the utilization of LAAO between racial and ethnic groups, and they appear to continue worsening from 2016 to 2019.