New TAVR centers disproportionately surfacing in wealthier metropolitan areas
Although 583 hospitals initiated new transcatheter aortic valve replacement programs from 2012 to 2018, the bulk went to wealthier metropolitan areas that already had existing TAVR programs, researchers reported.
According to a report published in Circulation: Cardiovascular Quality and Outcomes, not only were hospitals serving socioeconomically disadvantaged patients less likely to initiate new TAVR programs, but they also performed fewer TAVR procedures overall.
“Despite the potential benefits associated with the development of novel therapeutics, inequitable diffusion of new technologies preferentially to areas with high socioeconomic status may generate or worsen disparities in care and health inequities,” Ashwin Nathan, MD, fellow in cardiovascular medicine at the Hospital of the University of Pennsylvania, and colleagues wrote.
“Prior studies have demonstrated that patients living in rural environments are underrepresented among those patients undergoing TAVR, and there are concerns that geographic, racial and socioeconomic factors may contribute to inequities in access to TAVR,” the researchers wrote. “In fact, TAVR may be particularly sensitive to propagating inequities in care, given the need for multiple treating physicians, extensive specialized preprocedural testing, and surgical and interventional site-volume requirements for centers seeking to offer this therapy.”
To evaluate the characteristics of hospitals that developed TAVR programs and the socioeconomic demographics these hospitals served, researchers utilized the Medicare Provider Analysis and Review data files and the Master Beneficiary Summary File data to identify fee-for-service Medicare beneficiaries aged 66 years or older who underwent TAVR from 2012 to 2018. Hospitals that developed TAVR programs were defined as those performing 10 or more TAVR procedures during the study period.
Growth of TAVR from 2012 to 2018
During the study period, 98.1% hospitals that developed new TAVR programs were in metropolitan areas, 50.3% of which resided in metropolitan areas with preexisting TAVR programs.
“There are still barriers in geographic access for patients in rural communities to transcatheter aortic valve replacement,” Nathan told Healio. “As a community, we need to ensure that we are providing high-quality care to all people in our country, regardless of where they live.”
Hospitals that initiated new TAVR programs treated 2.83% fewer patients with dual eligibility for Medicaid (95% CI, 3.78 to 1.89; P .01), were in areas with $2,447 higher median household income (95% CI, 1,348-3,547; P = .03) and were from areas with lower distressed communities index scores (difference 4.02 units; 95% CI, 5.43 to 2.61; P .01), compared with hospitals that did not initiate TAVR programs.
“Creating a TAVR program likely requires a significant upfront financial investment by the hospital and health system to set up the infrastructure of a successful TAVR program,” Nathan told Healio. “In addition, given the lower margins with transcatheter aortic valve replacement, many hospitals may not be able to afford to start programs in the current market with the relationship of current reimbursement to current valve cost.”
Socioeconomic factors and TAVR procedures
According to the study, for every 1% increase in the proportion of patients who are dual eligible for Medicaid within a core-based statistical area, the number of TAVR procedures per 100,000 persons was 1.19% lower (95% CI, 1.34 to 1.04; P < .01).
For every $1,000 decrease in median household income within a statistical area, the number of TAVR procedures was 0.62% lower (95% CI, 0.67 to 0.56; P < .01).
In addition, for every 1 U increase in the distressed communities index, the number of TAVR procedures performed decreased 0.35% (95% CI, 0.38 to 0.32; P < .01).
“Improving access to TAVR programs among socioeconomically disadvantaged areas requires an investment by insurers, health systems and physicians to ensure that all subsets of the population are being considered for this life-saving procedure,” Nathan told Healio. “Strategies could include outreach efforts into rural and underserved areas to improve knowledge and awareness of the disease and treatment, streamlining the diagnostic and referral pathway to ease the process for patients who may have to make significant undertakings to be seen at a TAVR center, and changing reimbursements and valve costs to ensure that all hospitals have the financial ability to create and sustain high-quality programs.”
For more information:
Ashwin Nathan, MD, can be reached at ashwin.nathan@pennmedicine.upenn.edu.
Reference:
- Newer heart valve replacement treatment increased in the U.S. in wealthy, metro areas. newsroom.heart.org/news/newer-heart-valve-replacement-treatment-increased-in-the-u-s-in-wealthy-metro-areas. Published Oct. 21, 2021. Accessed Oct. 26, 2021.
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