Did ethno-racial disparities in access to transcatheter aortic valve replacement change over time?

Brian D Cohen; Nathan Aminpour; Haijun Wang; Frank W Sellke; Waddah B Al-Refaie; Afshin Ehsan

doi:10.1016/j.xjon.2022.07.009

Did ethno-racial disparities in access to transcatheter aortic valve replacement change over time?

JTCVS Open. 2022 Aug 5:12:71-83. doi: 10.1016/j.xjon.2022.07.009. eCollection 2022 Dec.

Authors

Brian D Cohen¹, Nathan Aminpour², Haijun Wang³, Frank W Sellke⁴, Waddah B Al-Refaie⁵, Afshin Ehsan⁴

Affiliations

¹ Department of Surgery, MedStar Georgetown/Washington Hospital Center, Washington, DC.
² Georgetown University School of Medicine, Washington, DC.
³ MedStar Health Research Institute, Hyattsville, Md.
⁴ Division of Cardiothoracic Surgery, Brown University Medical School/Rhode Island Hospital, Providence, RI.
⁵ Department of Surgery, MedStar Georgetown University Hospital, Washington, DC.

Abstract

Objective: In this study we sought to evaluate whether disparate use of transcatheter aortic valve replacement (TAVR) among non-White patients has decreased over time, and if unequal access to TAVR is driven by unequal access to high-volume hospitals.

Methods: From 2013 to 2017, we used the State Inpatient Database across 8 states (Ariz, Colo, Fla, Md, NC, NM, Nev, Wash) to identify 51,232 Medicare beneficiaries who underwent TAVR versus surgical aortic valve replacement. Hospitals were categorized as low- (<50 per year), medium- (50-100 per year), or high-volume (>100 per year) according to total valve procedures (TAVR + surgical aortic valve replacement). Multivariable logistic regression models with interactions were performed to determine the effect of race, time, and hospital volume on the utilization of TAVR.

Results: Non-White patients were less likely to receive TAVR than White patients (odds ratio [OR], 0.77; 95% CI, 0.71-0.83). However, utilization of TAVR increased over time (OR, 1.73; 95% CI, 1.73-1.80) for the total population, with non-White patients' TAVR use growing faster than for White patients (OR, 1.06; 95% CI, 1.00-1.12), time × race interaction, P = .034. Further, an adjusted volume-stratified time trend analysis showed that utilization of TAVR at high volume hospitals increased faster for non-White patients versus White patients by 8.6% per year (OR, 1.09; 95% CI, 1.01-1.16) whereas use at low- and medium-volume hospitals did not contribute to any decreasing utilization gap.

Conclusions: This analysis shows initial low rates of TAVR utilization among non-White patients followed by accelerated use over time, relative to White patients. This narrowing gap was driven by increased TAVR utilization by non-White patients at high-volume hospitals.

Keywords: DES, drug-eluting stent; ICD, International Classification of Diseases; OR, odds ratio; SAVR; SAVR, surgical aortic valve replacement; SID, State Inpatient Database; TAVR; TAVR, transcatheter aortic valve replacement; disparity; hospital volume; race/ethnicity.