Racial Disparities in the Utilization and Outcomes of Structural Heart Disease Interventions in the United States

Abstract

BackgroundData on race‐ and ethnicity‐based disparities in the utilization and outcomes of structural heart disease interventions in the United States are scarce.Methods and ResultsWe used the National Inpatient Sample (2011‐2016) to examine racial and ethnic differences in the utilization, in‐hospital outcomes, and cost of structural heart disease interventions among patients ≥65 years of age. A total of 106 119 weighted hospitalizations for transcatheter aortic valve replacement, transcatheter mitral valve repair, and left atrial appendage occlusion were included. The utilization rates (defined as the number of procedures performed per 100 000 US people >65 years of age) were higher in whites compared with blacks and Hispanics for transcatheter aortic valve replacement (43.1 versus 18.0 versus 21.1), transcatheter mitral valve repair (5.0 versus 3.2 versus 3.2), and left atrial appendage occlusion (6.6 versus 2.1 versus 3.5), respectively (P<0.001). Black and Hispanic patients had distinctive socioeconomic and clinical risk profiles compared with white patients. There were no significant differences in the adjusted in‐hospital mortality or key complications between patients of white race, black race, and Hispanic ethnicity following transcatheter aortic valve replacement, transcatheter mitral valve repair, or left atrial appendage occlusion. No difference in cost was observed between white and black patients following any of the 3 procedures. However, Hispanic patients incurred modestly higher cost with transcatheter mitral valve repair and left atrial appendage occlusion compared with white patients.ConclusionsRacial and ethnic disparities exist in the utilization of structural heart disease interventions in the United States. Nonetheless, adjusted in‐hospital outcomes were comparable among white, black, and Hispanic patients. Further studies are needed to understand the reasons for these utilization disparities.

Racial and ethnic differences in left atrial appendage occlusion wait time, complications, and periprocedural management

“…In addition to being sicker than whites, non‐white patients in our study were more likely to be impoverished, and may be more representative of urban populations in the United States 33 . The morbidity of patients in our study was similar to that which was found examining LAAO patients among different racial groups in the National Inpatient Sample, suggesting that our population may be more representative of what is observed outside clinical trials 14 …”

“…While it has been reported that blacks may have reduced access to LAAO, 14,34 we found that non‐whites, who were also poorer than whites in our study, had similar wait times for LAAO when compared to whites once they had been referred. Impoverished patients often have more obstacles to advanced forms of therapy such as LAAO, 16–18 and race‐related healthcare disparities in the United States persist after accounting for income 35 .…”

“…The incidence of procedural complications across racial and socioeconomic lines has been shown in catheter based and cardiac procedures, 41,42 although is not a uniform observation in other procedural populations 43 . A recent analysis of the National Inpatient Sample to assess racial and ethnic disparities in the utilization of structural heart disease interventions in the United States, including LAAO, revealed that while TAVR and LAAO may be under‐utilized in minorities, outcomes across racial lines are similar 14 . In our racially diverse population of consecutive patients undergoing LAAO, there was no difference in acute complications after LAAO, despite an increased prevalence of co‐morbidities.…”

“…Despite blacks with AF having a greater risk of embolic stroke, 11 and being more likely to have subtherapeutic anticoagulation and higher risk of hemorrhage when treated with warfarin for stroke prevention, 12 large trials examining the benefits of Watchman implant have markedly underrepresented blacks, who comprise less than 2% of study cohorts 6,7,9,13 . This may be, in part, due to a diminished referral pattern in blacks relative to whites for LAAO 14 and that whites may be more likely to embrace new therapeutic medical technologies 15 . These findings reflect a general trend in racial disparities in access to medical care, whereby non‐white and indigent patients face greater barriers to continuity of care and medical care, 16–18 including advanced therapies such as percutaneous coronary intervention, 19 and coronary bypass and valvular surgery 14,20,21 …”

“…This may be, in part, due to a diminished referral pattern in blacks relative to whites for LAAO 14 and that whites may be more likely to embrace new therapeutic medical technologies 15 . These findings reflect a general trend in racial disparities in access to medical care, whereby non‐white and indigent patients face greater barriers to continuity of care and medical care, 16–18 including advanced therapies such as percutaneous coronary intervention, 19 and coronary bypass and valvular surgery 14,20,21 …”