In mitral valve surgery, racial disparities exist in procedure type, survival
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Among those requiring mitral valve surgery, Black patients were less likely to undergo a minimally invasive procedure and more likely to die or experience a major complication compared with white patients, researchers reported.
“Disparities in CV medicine have been extensively documented in the past, especially when it comes to CV procedures,” Laurent G. Glance, MD, professor of anesthesiology and perioperative medicine at the University of Rochester Medical Center, told Healio. “We were interested in whether there were disparities in access to a new, cutting-edge technology — the use of minimally invasive mitral valve surgery.”
Glance and colleagues analyzed data from 103,753 patients who underwent mitral valve surgery between 2014 and 2019, using the Society of Thoracic Surgeons National Database, with patients stratified by white (85.8%), Black (10%) or Hispanic race/ethnicity (4.2%). The mean age of patients was 62 years and 46.2% were women. Researchers assessed the association between minimally invasive mitral valve surgery vs. full sternotomy and race and ethnicity.
The findings were published in JAMA Network Open.
Insurance status and surgery outcomes
Researchers found that Black patients were more than twice as likely to have Medicaid insurance compared with white patients (OR = 2.21; 95% CI, 1.64-2.98; P < .001) and were more than four times as likely to receive care from a low-volume surgeon (OR = 4.45; 95% CI, 4.01-4.93; P < .001) compared with white patients.
Compared with white patients, Black patients were less likely to undergo minimally invasive mitral valve surgery (OR = 0.65; 95% CI, 0.58-0.73; P < .001), whereas there was no difference between white and Hispanic patients (OR = 1.08; 95% CI, 0.67-1.75; P = .74).
Patients with commercial insurance had more than twice the odds of undergoing minimally invasive mitral valve surgery compared with those with Medicaid insurance (OR = 2.35; 95% CI, 2.06-2.68; P < .001).
“There are some twists in these findings that were interesting,” Glance said in an interview. “Black, but not Hispanic, individuals were less likely to receive a minimally invasive approach and were more likely to die or experience a major complication. However, Black patients were more likely to have Medicaid vs. commercial insurance. Why is that important? Patients with commercial insurance were much more likely to have minimally invasive surgery. That is an important mechanism, because when we think about health care reform, a big piece of that is Medicaid expansion. We have dramatically cut down on the number of uninsured individuals in the U.S., but that is due to expanding Medicaid. ... Simply having insurance is not enough in terms of getting access to this cutting-edge technology.”
High- vs. low-volume centers
Additionally, those who underwent procedures with very high-volume surgeons, defined as 300 or more cases, had 20.7-fold higher odds of undergoing minimally invasive mitral valve surgery compared with patients treated by low-volume surgeons, defined as less than 20 cases (OR = 20.7; 95% CI, 12.7-33.9; P < .001).
“In many areas of surgery, volume is a driver of outcome,” Peter W. Knight, MD, chief and Dr. Jude S. Sauer Family Distinguished Professor in Cardiac Surgery, told Healio. “In mitral valve surgery, volume is a pretty high driver of outcomes. Traditionally, one looks at the outcomes. In the mitral valve business, it starts one step before that. There is this cohort of patients that either goes into the mitral valve repair pathway or the mitral valve replacement pathway. We have known for a long time that replacement is not as good as repair. In a low-volume center, the rate of repair falls below 95%, and that frequently is not picked up.”
After adjusting for patient risk, Black patients were still less likely to undergo minimally invasive mitral valve surgery compared with white patients, with an adjusted OR of 0.88 (95% CI, 0.78-0.99; P = .04). Black patients were also still more likely to die or experience a major complication compared with white patients, with an aOR of 1.25 (95% CI, 1.16-1.35; P < .001).
Glance said the findings suggest that Medicaid expansion is likely inadequate and has led to segregated health outcomes by race.
“Medicaid expansion is laudable and a good thing, but it is probably a floor,” Glance told Healio. “It is not enough. One needs to think about the quality of the coverage. This is a strong example that having Medicaid does not equal the same level of access as people with commercial insurance.”
For more information:
Laurent G. Glance, MD, can be reached at laurent_glance@urmc.rochester.edu.
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