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Observational Study
. 2022 Feb 1;7(2):150-157.
doi: 10.1001/jamacardio.2021.4641.

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

Affiliations
Observational Study

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

Ashwin S Nathan et al. JAMA Cardiol. .

Abstract

Importance: Despite the benefits of high-technology therapeutics, inequitable access to these technologies may generate disparities in care.

Objective: To examine the association between zip code-level racial, ethnic, and socioeconomic composition and rates of transcatheter aortic valve replacement (TAVR) among Medicare patients living within large metropolitan areas with TAVR programs.

Design, setting, and participants: This multicenter, nationwide cross-sectional analysis of Medicare claims data between January 1, 2012, and December 31, 2018, included beneficiaries of fee-for-service Medicare who were 66 years or older living in the 25 largest metropolitan core-based statistical areas.

Exposure: Receipt of TAVR.

Main outcomes and measures: The association between zip code-level racial, ethnic, and socioeconomic composition and rates of TAVR per 100 000 Medicare beneficiaries.

Results: Within the studied metropolitan areas, there were 7590 individual zip codes. The mean (SD) age of Medicare beneficiaries within these areas was 71.4 (2.0) years, a mean (SD) of 47.6% (5.8%) of beneficiaries were men, and a mean (SD) of 4.0% (7.0%) were Asian, 11.1% (18.9%) were Black, 8.0% (12.9%) were Hispanic, and 73.8% (24.9%) were White. The mean number of TAVRs per 100 000 Medicare beneficiaries by zip code was 249 (IQR, 0-429). For each $1000 decrease in median household income, the number of TAVR procedures performed per 100 000 Medicare beneficiaries was 0.2% (95% CI, 0.1%-0.4%) lower (P = .002). For each 1% increase in the proportion of patients who were dually eligible for Medicaid services, the number of TAVR procedures performed per 100 000 Medicare beneficiaries was 2.1% (95% CI, 1.3%-2.9%) lower (P < .001). For each 1-unit increase in the Distressed Communities Index score, the number of TAVR procedures performed per 100 000 Medicare beneficiaries was 0.4% (95% CI, 0.2%-0.5%) lower (P < .001). Rates of TAVR were lower in zip codes with higher proportions of patients of Black race and Hispanic ethnicity, despite adjusting for socioeconomic markers, age, and clinical comorbidities.

Conclusions and relevance: Within major metropolitan areas in the US with TAVR programs, zip codes with higher proportions of Black and Hispanic patients and those with greater socioeconomic disadvantages had lower rates of TAVR, adjusting for age and clinical comorbidities. Whether this reflects a different burden of symptomatic aortic stenosis by race and socioeconomic status or disparities in use of TAVR requires further study.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Cohen has received research grant support and consulting fees from Edwards Lifesciences, Medtronic, Abbott, and Boston Scientific outside the submitted work. Dr Baron has served on an advisory board for Boston Scientific Corporation and Abiomed, has received grant support from Boston Scientific Corporation and Abiomed, and has been a consultant for Abbott, Abiomed, Edwards Lifesciences, and MitraLabs outside the submitted work. Dr Desai reports speaker and consultant fees from Gore, Medtronic, and Terumo and grants from Gore and Medtronic outside the submitted work. Dr Szeto reports investigator and advisory board fees from Edwards Lifesciences and Medtronic. Dr Herrmann reports institutional research funding from Abbott Vascular, Boston Scientific, Edwards Lifesciences, and Medtronic and consulting fees and honoraria from Edwards Lifesciences and Medtronic during the conduct of the study, as well as grants from Ancora, Shockwave, and Gore and equity from Holistick Medical and Microinterventional Devices outside the submitted work. Dr Giri has served on an advisory board for AstraZeneca and received research support to the institution from Recor Medical and St. Jude Medical; Dr Giri also reported personal fees from Boston Scientific, Inari Medical, AstraZeneca, and Philips Medical and grants from Boston Scientific and Inari Medical outside the submitted work. Dr Fanaroff receives research support from the American Heart Association and Boston Scientific and honoraria from the American Heart Association outside the submitted work. Dr Khatana reported grants from National Heart, Lung, and Blood Institute (grant 1K23HL153772-01) and American Heart Association (grant 20CDA35320251) during the conduct of the study. Dr Vemulapalli reported grants from American College of Cardiology, Society of Thoracic Surgeons, Abbott Vascular, and Boston Scientific outside the submitted work; and grants or contracts from the US Food and Drug Administration (Nest CC); National Institutes of Health (R01 and Small Business Innovation Research) and Cytokinetics; consulting and advisory board involvement with Boston Scientific, Janssen, HeartFlow, and the American College of Physicians. Dr Nallamothu reported being a principal investigator or coinvestigator on research grants from the National Institutes of Health, Veterans Administration Health Science Research and Development, the American Heart Association, Apple, Toyota, and Janssen. Dr Nallamothu also receives compensation as editor-in-chief of Circulation: Cardiovascular Quality & Outcomes, a journal of the American Heart Association, and is a coinventor on US utility patent US 9,962,124 as well as a provisional patent application (54423), which both use software technology with signal processing and machine learning to automate the reading of coronary angiograms and are held by the University of Michigan and licensed to AngioInsight Inc, in which he holds ownership shares and receives consultancy fees. The University of Michigan also has filed patents on Dr Nallamothu’s behalf on the use of computer vision for imaging applications in gastroenterology, with technology elements licensed to Applied Morphomics Inc, in which he has no relationship or stake. No other disclosures were reported.

Figures

Figure.
Figure.. Choropleths
Choropleths demonstrate geographic variation in the age-adjusted rate of transcatheter aortic valve replacement (TAVR) performed per 100 000 Medicare beneficiaries, as well as the proportion of patients dually eligible for Medicaid and the proportion of Black or Hispanic patients for each zip code within the Philadelphia, Pennsylvania–Camden, New Jersey–Wilmington, Delaware Core-Based Statistical Area.

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References

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