Racial, Ethnic, and Socioeconomic Inequities in Access to Left Atrial Appendage Occlusion

Abstract

Background Inequitable access to high‐technology therapeutics may perpetuate inequities in care. We examined the characteristics of US hospitals that did and did not establish left atrial appendage occlusion (LAAO) programs, the patient populations those hospitals served, and the associations between zip code–level racial, ethnic, and socioeconomic composition and rates of LAAO among Medicare beneficiaries living within large metropolitan areas with LAAO programs. Methods and Results We conducted cross‐sectional analyses of Medicare fee‐for‐service claims for beneficiaries aged 66 years or older between 2016 and 2019. We identified hospitals establishing LAAO programs during the study period. We used generalized linear mixed models to measure the association between zip code–level racial, ethnic, and socioeconomic composition and age‐adjusted rates of LAAO in the most populous 25 metropolitan areas with LAAO sites. During the study period, 507 candidate hospitals started LAAO programs, and 745 candidate hospitals did not. Most new LAAO programs opened in metropolitan areas (97.4%). Compared with non‐LAAO centers, LAAO centers treated patients with higher median household incomes (difference of $913 [95% CI, $197–$1629], P =0.01). Zip code–level rates of LAAO procedures per 100 000 Medicare beneficiaries in large metropolitan areas were 0.34% (95% CI, 0.33%–0.35%) lower for each $1000 zip code–level decrease in median household income. After adjustment for socioeconomic markers, age, and clinical comorbidities, LAAO rates were lower in zip codes with higher proportions of Black or Hispanic patients. Conclusions Growth in LAAO programs in the United States had been concentrated in metropolitan areas. LAAO centers treated wealthier patient populations in hospitals without LAAO programs. Within major metropolitan areas with LAAO programs, zip codes with higher proportions of Black and Hispanic patients and more patients experiencing socioeconomic disadvantage had lower age‐adjusted rates of LAAO. Thus, geographic proximity alone may not ensure equitable access to LAAO. Unequal access to LAAO may reflect disparities in referral patterns, rates of diagnosis, and preferences for using novel therapies experienced by racial and ethnic minority groups and patients experiencing socioeconomic disadvantage.

Patient Characteristics Associated With Using Transcatheter Left Atrial Appendage Occlusion Versus Oral Anticoagulants for Atrial Fibrillation

“…In this cohort of patients with AF, 30 1; Figure 1). In 2020, LAAO accounted for 9.32% of all patients receiving either LAAO or OACs.…”

“…This is consistent with a recent study showing zip codes with a higher proportion of Black or Hispanic patients had lower LAAO rates. 30 Another study reported that non-White patients had worse outcomes following LAAO implantation. 31 One hypothesis underlying such differential outcomes is that LAAO for non-White patients is more likely to be performed at centers with lower volume and experience, [32][33][34][35][36] which warrants future investigation for confirmation.…”

Racial and Ethnic Disparities in the Utilization and Outcomes with WATCHMAN FLX: A SURPASS analysis of the NCDR LAAO Registry

“…An analysis of Medicare fee-for-service claims (2016 to 2019) by Reddy and colleagues revealed that between 2016 and 2019, 97.4% of new LAAO programs opened in the US were in metropolitan areas. 7 The authors found that LAAO centers, as compared to non-LAAO centers, provided care to patients with higher median household incomes. After adjustment for socioeconomic markers, age, and clinical comorbidities, LAAO procedures were less likely to be performed in zip codes with higher proportions of Black and Hispanic patients.…”

“…After adjustment for socioeconomic markers, age, and clinical comorbidities, LAAO procedures were less likely to be performed in zip codes with higher proportions of Black and Hispanic patients. 7 Another important consideration that affects the demographic composition of those who undergo LAAO procedures is that White patients have a higher risk of AF than other racial and ethnic groups. 4 However, this only explains some of the underrepresentation of racial and ethnic minority groups among LAAO patients.…”

Natural Language Processing to Identify Racial and Ethnic Disparities in Aortic Stenosis

“…[10][11][12][13] In addition to AS, health inequity has been noted to influence outcomes in a wide range of medical conditions. [14][15][16][17] We hypothesised that race and ethnicity significantly impact AS diagnosis, management and outcomes within a universal healthcare system (Figure 1a). We conducted a retrospective study using longitudinal electronic health record (EHR) data from a tertiary UK hospital (Figure 1b).…”