The uneven growth of TAVR programs leaves the poorest communities behind

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Inequalities in the initial growth of catheter aortic valve replacement A new cross-sectional study suggests that programs (TAVRs) in American hospitals have led to less use of the transformational procedure in poorer communities.

Using Medicare claims data, researchers identified 554 new TAVR programs created between January 2012 and December 2018.

Of these, 98% were established in metropolitan areas (> 50,000 residents) and 53% were initiated in areas with pre-existing TAVR programs, “thus increasing the number of programs but not necessarily increasing the geographical availability of the procedure.” , said study author Ashwin Nathan, MD, University of Pennsylvania Hospital, Philadelphia.

Only 11 programs were initiated in non-metropolitan areas during the study period, he noted during the presentation of the clinical research at the 2021 virtual meeting of the Society for Cardiovascular Angiography and Interventions (SCAI).

Hospitals that established TAVR programs, compared with those that did not, treated patients with higher median family incomes (difference, $ 1305; Pg = .03) and areas with better economic well – being based on the Index of communities in difficulty (difference, –3.15 units; Pg <0.01), and treated fewer patients with dual Medicaid eligibility (difference, –3.15%; Pg <.01).

When the researchers examined TAVR rates among core-based statistical areas, there were fewer TAVR procedures per 100,000 Medicare recipients in areas with more dual Medicaid eligible patients (difference, –1.19% to 1%). of increase), average household income (difference, –0.62% for every $ 1,000 decrease), and more average community distress (difference, –0.35% for every 1 unit of increase); Pg <.01 for all).

“What we can conclude is that the increase in the number of TAVR programs we found during the study period did not necessarily translate into increased access to TAVR …. The richest and most privileged patients had more access. at TAVR thanks to the hospitals that serve them, ”Nathan said.

He said future steps are to identify the role of race and ethnicity in unequal access to TAVR, identify system-level and patient-level access barriers, and develop and test solutions to address inequity care.

Elaborating this last point during a discussion of the results, study co-author Jay S. Giri, MD, MPH, also of the University of Pennsylvania Hospital, noted that although the data show that the areas rural areas are left behind, not all parts of an urban area act as the area more generally.

As a result, they are delving into the 25 largest urban areas and trying to disaggregate, based on both socioeconomic status and the race in the area, if there are inequalities, he said. Believe it or not, in some urban areas where there is clear access (there may even be a dozen TAVR programs within a 25 mile radius), some of these areas continue to act as rural areas that do not have access. “That’s it.”

The co-chair of the session, Steven Yakubov, MD, MidWest Cardiology Research Foundation in Columbus, Ohio, said the results show that TAVR programs are usually developed in well-attended areas, but asked if part of the responsibility lies with the patients to seek medical attention. “Are we just not giving enough education to patients on how to access care?”

Giri responded by highlighting the complexity of navigation even from being diagnosed aortic stenosis to do so through a multidisciplinary TAVR assessment.

“People with higher health literacy and more means are more likely to overcome this glove. But from a public health perspective, I would obviously say that the responsibility of the medical community is probably greater to figure out how to do it. “These programs are more widespread,” he said.

“We felt that market forces seemed to be driving the development of new TAVR programs on access to healthcare considerations,” Giri added. “And just to point out, these market forces are not at the level of device manufacturers, who are often denounced for their cost. This is really about market forces at the level of hospitals and health systems.”

Session coordinator Megan Coylewright, MD, MPH, Erlanger Heart and Lung Institute, Chattanooga, Tennessee, said, “I think that’s very well said,” and noted that doctors might also have some responsibility.

“From the responsibility of a doctor, especially with regard to the structural heart, we tended to add all together, all of us who have structural cardiac training or who we have trained in certain institutions,” he said. “It’s definitely up to us to continue to expand and go to the communities that need it to ensure access. I think, as Dr. Giri said, there are a lot of solutions and that should be the focus for the next two years.”

Nathan reported that he had no relevant disclosures. Giri reported that he had been a principal investigator for a research study at Boston Scientific, Inari Medical, Abbott and Recor Medical; consulting for Boston Scientist; and as part of an advisory board of Inari Medical.

Society of Angiography and Cardiovascular Interventions (SCAI) 2021: Summary FCR-05. Filed April 29, 2021.

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