Low Socioeconomic Status Linked to Lower Rates of TAVR in Aortic Stenosis Treatment

Ashwin S. Nathan, MD, MS

Although there is a known benefit of transcatheter aortic valve replacement (TAVR) in the treatment and management of aortic stenosis (AS), barriers to access may include proximity to programs and biases in care delivery, particularly in communities with low socioeconomic status.

In order to better understand these associated barriers, a recent study examined the link between zip code-level racial, ethnic, and socioeconomic composition and rates of TAVR among Medicare patients in large metropolitan areas with TAVR programs.

Led by Ashwin S. Nathan, MD, MS, Division of Cardiology, Hospital of the University of Pennsylvania, a team of investigators thus observed that, in fact, zip codes with higher proportions of Black and Hispanic patients, as well as those with greater socioeconomic disadvantages, had lower rates of TAVR.

Methods

The methodology of the study was based on a multi-center, nationwide cross-sectional analysis of Medicare claims data. Data was obtained from the Medicare Hospital Claims and Demographic Data files on patient and hospital zip code.

Then, they were assigned to individual core-based statistical areas (CBSAs) using zip code data from the US Department of Housing crosswalk files. CBSAs are defined as distinct geographic areas consisting of an urban center and surrounding counties socioeconomically linked to the urban center with a population of at least 50,000 people.

Nathan and colleagues identified the 25 largest metropolitan CBSAs by population from the 2010 US census, among CBSAs with at least 1 hospital with a TAVR program that performed ≥1 TAVR between January 2012 - December 2018. Data identified Medicare fee-for-service beneficiaries 66 years or older who underwent TAVR.

Additionally, they collected data on race and ethnicity, as well as socioeconomic status through median household income based on zip code, dual-eligibility status for Medicaid, and the Distressed Communities Index (DCI) score. The DCI combined 7 economic indications with a range of 0 (least distressed) to 100 (most distressed).

The primary outcome for the study was considered the age-adjusted rate of TAVR per 100,000 Medicare beneficiaries for each zip code within the 25 largest metropolitan CBSA during the study period.

Findings

In the 25 largest CBSAs with TAVR programs studied, there were 7590 individual zip codes, with the median number of TAVR centers per CBSA at 7. Data show the mean age of Medicare beneficiaries within these areas was 71.4 years, with a mean of 47.6% of beneficiaries were men.

Further, data show a mean of 4.0% of beneficiaries were Asian, 11.1% were Black, 8.0% were Hispanic, and 73.8% were White. The median household income was shown to be $62,348 ($46,559 - $83,206), while the median DCI score was 28.6 (11.9 - 56.1).

In the studied programs, the median rate of TAVR per 100,000 Medicare beneficiaries by zip code was 249 (IQR, 0 - 429). In addition, the unadjusted rates of TAVR per 100,000 Medicare beneficiaries were lower among Black and Hispanic patients, in comparison to White patients in each tertile of median household income.

The team observed that for each $1,000 decrease in median household income, the number of TAVR procedures performed per 100,000 Medicare beneficiaries was 0.2% (95% CI, 0.1% - 0.4%) lower (P = .002).

Following that, for each 1% increase in the proportion of patients dually eligible for Medicaid services, the number of TAVR procedures performed per 100,000 Medicare beneficiaries was 2.1% (95% CI, 1.3% - 2.9%) lower (P < .001).

In addition, for each 1-unit increase in the DCI score, the number of TAVR procedures performed per 100,000 Medicare beneficiaries was 0.4% (95% CI, 0.2% - 0.5%) lower (P <.001).

After adjustment for median household income, each 1% increase in the proportion of Black patients within a zip code showed the number of TAVR procedures performed decreased by 1.1% (95% CI, 0.6%-1.7%; P < .001). Each 1% increase in the proportion of Hispanic patients showed the number of TAVR procedures decreased by 1.2% (95% CI, 0.2% - 2.2%; P = .03).

Takeaways

“While it is unclear whether this reflects different burdens of symptomatic aortic stenosis by race and socioeconomic status or disparities in use of TAVR, these findings may suggest that access to high-technology therapeutics require more than geographic proximity and adequate health insurance and systemic barriers can limit the receipt of high-technology health care by marginalized populations,” investigators wrote.

The study, “Racial, Ethnic, and Socioeconomic Disparities in Access to Transcatheter Aortic Valve Replacement Within Major Metropolitan Areas,” was published in JAMA Cardiology.