Socioeconomic, race-based disparities reported in access to TAVR
In metropolitan U.S. areas with transcatheter aortic valve replacement programs, ZIP codes with higher proportions of Black and Hispanic patients and those with greater socioeconomic disadvantages had lower rates of TAVR, findings showed.
According to Ashwin S. Nathan, MD, MS, assistant professor of medicine at the Hospital of the University of Pennsylvania, there have been recent data on underrepresentation of minority populations among patients undergoing the procedure. “We wanted to perform a more comprehensive analysis to identify inequities in access to TAVR among minority populations as well as socioeconomically disadvantaged groups who live within the same geographic areas as TAVR programs,” Nathan told Healio.
For the study, Nathan and colleagues performed a multicenter, nationwide cross-sectional analysis of Medicare claims data from 2012 to 2018. They included beneficiaries of fee-for-service Medicare (aged 66 years) who were living in the 25 largest metropolitan core-based statistical areas.
The relationship between ZIP code-level racial, ethnic and socioeconomic composition, and rates of TAVR per 100,000 Medicare beneficiaries served as the main outcome measure.
In all, researchers studied 7,590 individual ZIP codes. The mean Medicare beneficiary age within these areas was 71 years. Among beneficiaries, 48% were men, whereas 4% were Asian, 11% were Black, 8% were Hispanic and 74% were white.
Inequity in TAVR access
Data revealed that the mean number of TAVRs per 100,000 Medicare beneficiaries by ZIP code was 249.
With each $1,000 decrease in median household income, TAVR procedures performed per 100,000 Medicare beneficiaries decreased by 0.2% (95% CI, 0.1-0.4; P = .002). Additionally, with each 1% increase in the proportion of patients dually eligible for Medicaid services, TAVR procedures performed per 100,000 Medicare beneficiaries fell by 2.1% (95% CI, 1.3-2.9; P < .001).
Furthermore, each 1 U increase in the Distressed Communities Index score lowered the TAVR procedures performed per 100,000 Medicare beneficiaries by 0.4% (95% CI, 0.2-0.5; P < .001).
After adjusting for socioeconomic markers, age and clinical comorbidities, researchers observed lower TAVR rates in ZIP codes with higher proportions of individuals of Black race and Hispanic ethnicity.
“This study demonstrates that areas with higher proportions of Black and Hispanic patients, as well as areas with greater socioeconomic disadvantage, have lower rates of TAVR,” Nathan said in an interview. “This suggests an inequity in access to this procedure. However, TAVR is the last step in a complex diagnostic and referral pathway that includes primary care, cardiology, imaging and multiple visits with physicians. It is important that we study this whole pathway to identify solutions to this inequity.”
Assessing the disparities
In an accompanying editorial, Clyde W. Yancy, MD, MSc, of Northwestern University, and Ajay Kirtane, MD, SM, of Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, wrote that, as the current analyses indicate, disentangling race from the entirety of the social construct is a complex and uncertain exercise.
“Is it possible that there are race-based biases impacting TAVR at the patient level? Yes. Is it proven? No,” they wrote. “Equity in access to care and completeness of clinical assessment, including even a careful physical examination, also come into play when assessing disparities in a ‘downstream’ procedure such as TAVR.”
When trying to determine where the truth resides, Yancy and Kirtane agreed with the study authors that access to and referral for high technology procedures predicated on team-based decision-making are subject to bias.
“But, race per se is not the sole culprit explanation,” they noted. “Until more research and research methodology evolve, we must do more to recognize our possible biases and concomitantly exercise caution before concluding race-based disparities in the utilization of TAVR. We can be empathic, but we must also be sure.”
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