Association of race and socioeconomic status with the use of endovascular repair to treat thoracic aortic diseases

Abstract

Objective Descending thoracic aortic diseases may be treated with either open thoracic aortic repair or thoracic endovascular aortic repair (TEVAR). Previous studies have demonstrated that race and socioeconomic status (SES) affect access to care and treatment allocation in vascular surgery. We hypothesized that racial minorities and lower SES patients have decreased propensity to have their thoracic aortic disease treated with TEVAR. Methods Weighted discharge records for patients who underwent either open thoracic aortic repair or TEVAR between 2005 and 2008 were evaluated using the Nationwide Inpatient Sample. Patient records were stratified by therapeutic intervention (open repair vs TEVAR). Differences in baseline comorbidities, race, and SES were compared. To account for the effects of comorbidities and other factors, hierarchical logistic regression modeling was used to determine the likelihood for TEVAR performance based on differences in patients’ race and SES. Results A total of 60,784 thoracic repairs were analyzed, the majority (79.4%) of which were open repairs. The most common race was white (78.2%), followed by black (9.1%), Hispanic (5.7%), Asian or Pacific Islander (2.9%), and Native American (0.7%). Patients were divided into quartiles according to SES with 20.6% of patients in the lowest SES quartile, 24.3% in the second quartile, 26.4% in the third quartile, and 28.8% in the highest SES quartile. Indications for treatment were similar for both treatment groups. After adjusting for multiple patient and hospital factors, race and SES were significantly associated with treatment modality for thoracic aortic disease. Black, Hispanic, and Native American populations had increased adjusted odds ratios of TEVAR performance compared with white patients. Similarly, lower SES correlated with increased use of TEVAR. Conclusions Contrary to our initial hypothesis, racial minorities (Black, Hispanic, and Native American) and patients with lower median household incomes have a greater association with the performance for TEVAR after accounting for patient comorbid disease, indication for treatment, payer status, and hospital volume. These results indicate that traditional racial disparities do not persist in TEVAR allocation.

The nature versus nurture debate continues for outcomes of thoracic endovascular aortic repair

“…For TEVAR specifically, Johnston et al 8 concluded that traditional racial disparities do not persist in TEVAR allocation between multiple races (e.g., White, Black, Hispanic, Asian or Pacific Islander, Native American), which is in line with the present study that observed that Black people have increased access to TEVAR over the last years. Moreover, a recent report by Yin et al 9 found lower 30-day and 1-year mortality rates in Black patients as compared to White patients treated with TEVAR for aortic aneurysm or aortic dissection.…”

Impact of ethnicity and race on outcomes after thoracic endovascular aortic repair

“…and patients with lower median household incomes had a higher propensity for undergoing TEVAR procedures. 9 We could observe a relative increase in the TEVAR incidence rate during 2013-2015 for the Black population in this opportunity. This trend could be related to some national health reforms implemented during the same period.…”

“…11 This paradigm was challenged by two reports, including data from 1999 to 2008, where we could observe a setting-off of traditional racial disparities with TEVAR utilization. 8,9 Given that more than a decade has already passed, our objective is to reevaluate if TEVAR continues to be a procedure where access to surgical services is not affected by racial differences using a contemporary database.…”

“…However, the incursion of TEVAR technology into medical practice suggested a process of “democratizing technology.” Historically, Black patients were more likely to undergo open repair for thoracic aortic aneurysms (TAAs) at low‐volume hospitals with higher operative mortality than White patients 11 . This paradigm was challenged by two reports, including data from 1999 to 2008, where we could observe a setting‐off of traditional racial disparities with TEVAR utilization 8,9 . Given that more than a decade has already passed, our objective is to reevaluate if TEVAR continues to be a procedure where access to surgical services is not affected by racial differences using a contemporary database.…”

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

“…[22][23][24] The rapidly expanding use of thoracic endovascular aortic repair over open repair provides a recent example of a revolutionary cardiovascular technology. Johnston and colleagues 25 reported that counter to their hypothesis, racial/ethnic minorities and patients with lower socioeconomic status were more likely to receive thoracic endovascular aortic repair over traditional open repair despite a previously described baseline disparity. Even after controlling for baseline comorbidity and treatment indication, they reasoned that greater disease severity and aneurysm morphology might not have been fully captured in their statistical controls, leading vulnerable populations to preferentially undergo the less invasive therapy.…”