Male patients, Black patients, rural residents more likely to die of pulmonary embolism
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Key takeaways:
- Death due to pulmonary embolism was more prevalent in male patients, Black patients and rural area residents.
- Mortality rates among male and Black patients significantly increased from 2006 to 2019.
Male patients, Black patients and rural area residents with pulmonary embolism had poorer age-adjusted mortality rates than their respective opposing demographics, according to results published in Annals of the American Thoracic Society.
“These findings are surprising and counterintuitive to the advancement in care for patients with pulmonary embolism over the last decade, as well as other studies suggesting a downward trajectory in mortality from other major causes of cardiovascular death,” Mohamed Zghouzi, MD, cardiology fellow at the University of Tennessee Health Science Center, said in a Michigan Medicine press release.
In a retrospective cohort analysis, Zghouzi and colleagues assessed 109,992 patients (54.7% female; 76.4% white) aged at least 15 years who died due to PE from 2006 to 2019 in the CDC and Prevention Wide-Ranging Online Data for Epidemiologic Research database to understand national mortality trends and how this rate changes according to sex, race and geographic location.
In 2019, the age-adjusted mortality rate for PE was 2.81 per 100,000 people, which appeared similar to the rate observed earlier in 2006 (2.84 per 100,000 people), with an average annual percentage change (AAPC) of 0.2 (95% CI, –0.1 to 0.5).
When divided based on sex, researchers found that PE-related mortality occurred among more male patients than female patients (2.92 per 100,000; 95% CI, 2.9-2.95 vs. 2.82 per 100,000; 95% CI, 2.8-2.84), and this trend continued as time progressed (2006-2019 AAPC: men, 0.7; 95% CI, 0.3-1.2 vs. women, –0.4; 95% CI, –1.1 to 0.3).
According to race/ethnicity, age-adjusted mortality rates per 100,000 population for the 2006 to 2019 period were highest among Black individuals (5.26; 95% CI, 5.19-5.34) compared with white (2.91; 95% CI, 2.89-2.93) and Hispanic (1.2; 95% CI, 1.17-1.24) individuals.
From 2006 to 2019, researchers further observed a significant increase in this rate for Black individuals (AAPC, 0.4; 95% CI, 0-0.7), whereas the changes over time were not significant among white (AAPC, 0; 95% CI, –0.6 to 0.6) and Hispanic (AAPC, –0.2; 95% CI, –1.1 to 0.7) individuals.
In terms of geographic location, more patients from rural areas died of PE (4.07 per 100,000; 95% CI, 4.02-4.12) than patients living in micropolitan (3.24 per 100,000; 95% CI, 3.21-3.27) or large metropolitan areas (2.32 per 100,000; 95% CI, 2.3-2.34) based on age-adjusted rates.
Researchers did not find an overall significant change in mortality among rural area residents from 2006 to 2019, although the age-adjusted mortality rate significantly increased between 2011 and 2015 (AAPC, 3.8; 95% CI, 0.8-6.9) and then significantly decreased at almost the rate between 2015 and 2019 (AAPC, –3.7; 95% CI, –5.4 to –1.9).
Additionally, among the four regions, age-adjusted mortality rates from 2006 to 2019 only significantly increased in the Midwest (AAPC, 0.4; 95% CI, 0.1-0.8).
“These disparities underscore the need for multifaceted broad-based interventions, including increased funding for research focused on investigating the underlying causes, educational initiatives to increase awareness and programs aimed at improving outcomes for PE all patients, specifically targeting those in whom PE may be underrecognized or undertreated,” Zghouzi and colleagues wrote.
Reference:
- Pulmonary embolism deaths, disparities high despite advancements in care. https://www.michiganmedicine.org/health-lab/pulmonary-embolism-deaths-disparities-high-despite-advancements-care. Published Aug. 31, 2023. Accessed Sept. 1, 2023.
Perspective
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Despite focus and increased awareness of venous thromboembolism, specifically PE, in the United States, the mortality surrounding the disease is still unacceptably high. Zghouzi and colleagues provide an updated review of mortality related to PE in the United States over the last one and a half decades attempting to identify where to focus our treatment efforts next. Their data highlight that despite many advances in PE care, namely the use of catheter-directed therapy and the adoption of PE response teams, or PERTs, mortality has not decreased over the study period of January 2006 to December 2019.
The study identifies mortality rate by populations accounting for gender, race/ethnicity and geographic region. Perhaps disturbingly, Black individuals had an increase in mortality over the study period, whereas this was not observed among other race/ethnicity cohorts, although males also saw a rise in mortality. Overall, male and Black individuals had a higher mortality over the study period. Geographically, rural areas have the highest mortality compared with micropolitan and metropolitan areas. Southern states had a higher mortality than other geographic regions.
Although socioeconomics and insurance status may play a role in these disparities, Hispanic individuals did not show the same increase as Black individuals despite having similar baselines in these social determinates of health. This raises concern that the issue lays in factors not clearly understood and the CDC database from where the data were derived is deidentified and inherently vague. Although this feature of the data is essential for allowing for population-level analysis, much nuance is invariably lost.
The paper ultimately serves as a thought-provoking steppingstone upon which to ask a multitude of other questions that may inform our care of patients with PE. Are some of the underlying factors driving disparity in PE care among Black patients the same as those driving worse maternal-fetal outcomes in this population? Is the time to presentation delayed in rural areas, or are people presenting to care but unable to access advanced interventions in a timely manner?
This article answers some important questions, but more essentially places a spotlight on the many other unanswered questions that require the field's urgent attention and investigation.
Shari B. Brosnahan, MD, MSc, assistant professor in the division of pulmonary, critical care and sleep medicine at NYU Langone Health, senior assistant program director of the pulmonary and critical care fellowship at NYU Langone Health and investigator in the NYU Langone Translational Lung Biopsy Laboratory, also contributed to this Perspective.
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