Lower Rates of TAVR in Neighborhoods With Higher Numbers of Minorities, Poor

NEW YORK (Reuters Health) – In major metropolitan areas with transcatheter aortic-valve replacement (TAVR) programs, poorer neighborhoods and those with more Black and Hispanic people have lower rates of the minimally invasive surgery, a new study finds.

An analysis of Medicare data from 7,590 zip codes revealed that even after adjusting for socioeconomic markers, age and clinical comorbidities, rates of TAVR remained lower in zip codes with higher proportions of Black and Hispanic patients, researchers report in JAMA Cardiology.

“Even when patients have geographic access to TAVR, there appear to be inequities in access to the procedure among Black, Hispanic and socioeconomically disadvantaged patients,” said lead author Dr. Ashwin Nathan of the University of Pennsylvania’s Perelman School of Medicine in Philadelphia.

“The etiology for inequities in access are likely multifactorial,” Dr. Nathan told Reuters Health by email. “TAVR is the last step in a complex and multistep diagnostic/referral pathway that starts with health maintenance in a primary-care office, and includes subspecialty referral, multiple imaging and diagnostic tests and ultimate referral for TAVR. Where the ‘lesion’ is in this pathway that is causing inequities in access needs to be studied more so that solutions can be developed to address the inequity.”

To take a closer look at whether there were racial and ethnic disparities in receipt of TAVR in metro areas where centers offering the procedure would be relatively close to where patients lived, Dr. Nathan and his colleagues turned to the Medicare Hospital Data Claims and Demographic Data files.

The researchers focused on core-based statistical areas (CBSAs), which are defined by the U.S. Office of Management and Budget as distinct geographic areas consisting of an urban center and surrounding counties that are socioeconomically linked to the urban center. Dr. Nathan and his colleagues found that within the 25 largest CBSAs with TAVR programs between 2012 and 2018, there were 7,590 individual zip codes.

The median rate of TAVR per 100,000 Medicare beneficiaries in those CBSAs was 249. Unadjusted rates of TAVR per 100,000 beneficiaries were lower among Black and Hispanic patients compared with white patients across each tertile of median household income.

When the researchers divided zip codes into tertiles by markers of socioeconomic status, age-adjusted rates of TAVR were significantly higher in zip codes with higher median incomes compared with lower median incomes (317.5 vs. 170 per 100,000). Similarly, age-adjusted rates of TAVR were significantly higher in the zip codes with the lowest proportion of patients dually eligible for Medicaid compared with those with the highest proportion (310 vs. 178.5 per 100,000).

Dr. Nathan and his colleagues found that for each $1,000 decrease in median household income, the number of TAVR procedures performed per 100,000 Medicare beneficiaries was 0.2% lower. For each 1% increase in the proportion of patients who were dually eligible for Medicaid services, the number of TAVR procedures performed per 100,000 Medicare beneficiaries was 2.1% lower.

Rates of TAVR were significantly lower in zip codes with higher proportions of Black and Hispanic patients, even after adjusting for socioeconomic markers, age and clinical comorbidities.

“We have a responsibility as a medical community to ensure equitable access to life-saving procedures such as TAVR,” Dr. Nathan said. “It is imperative that we take action to remedy the inequities found in this project.”

The new study “raises awareness,” said Dr. Gilbert Tang, surgical director of the structural heart program at the Mount Sinai Health System in New York City.

“What we don’t know is whether there are other non-identifiable factors that lead to this discrepancy,” Dr. Tang said. Even an area with a high density of centers, patients still may have difficulties traveling to a center, he added.

“Elderly patients, for example, might need help getting to a medical center to get treatment or evaluation for TAVR,” Dr. Tang said. “Evaluation can be quite extensive and taxing to these patients. We see some families who can’t bring a family member in for evaluation without taking time off work. Or they may have to find childcare.”

Those types of factors won’t be captured in a database, Dr. Tang said. “I don’t think you can pinpoint race as the only reason some patients are not getting therapy,” he added. “It might just be a marker for something more complex.”

SOURCE: https://bit.ly/3nrpCHY and https://bit.ly/30z2JtP JAMA Cardiology, online November 17, 2021.

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