Socioeconomic disparities in procedural choice and outcomes after aortic valve replacement

Paige E Brlecic; Katie J Hogan; John A Treffalls; Christopher B Sylvester; Joseph S Coselli; Marc R Moon; Todd K Rosengart; Subhasis Chatterjee; Ravi K Ghanta

doi:10.1016/j.xjon.2023.10.002

Socioeconomic disparities in procedural choice and outcomes after aortic valve replacement

JTCVS Open. 2023 Oct 14:16:139-157. doi: 10.1016/j.xjon.2023.10.002. eCollection 2023 Dec.

Authors

Paige E Brlecic¹, Katie J Hogan^{1

2}, John A Treffalls^{1

3}, Christopher B Sylvester^{1

2}, Joseph S Coselli^{1

4}, Marc R Moon^{1

4}, Todd K Rosengart^{1

4}, Subhasis Chatterjee^{1

4}, Ravi K Ghanta^{1

4}

Affiliations

¹ Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex.
² Medical Scientist Training Program, Baylor College of Medicine, Houston, Tex.
³ Long School of Medicine, University of Texas Health San Antonio, San Antonio, Tex.
⁴ Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, Tex.

Abstract

Objective: To identify potential socioeconomic disparities in the procedural choice of patients undergoing surgical aortic valve replacement (SAVR) versus transcatheter aortic valve replacement (TAVR) and in readmission outcomes after SAVR or TAVR.

Methods: The Nationwide Readmissions Database was queried to identify a total of 243,691 patients who underwent isolated SAVR and TAVR between January 2016 and December 2018. Patients were stratified according to a tiered socioeconomic status (SES) metric comprising patient factors including education, literacy, housing, employment, insurance status, and neighborhood median income. Multivariable analyses were used to assess the effect of SES on procedural choice and risk-adjusted readmission outcomes.

Results: SAVR (41.4%; 100,833 of 243,619) was performed less frequently than TAVR (58.6%; 142,786 of 243,619). Lower SES was more frequent among patients undergoing SAVR (20.2% [20,379 of 100,833] vs 19.4% [27,791 of 142,786]; P < .001). Along with such variables as small hospital size, drug abuse, arrhythmia, and obesity, lower SES was independently associated with SAVR relative to TAVR (adjusted odds ratio [aOR], 1.17; 95% confidence interval [CI], 1.11 to 1.24). After SAVR, but not after TAVR, lower SES was independently associated with increased readmission at 30 days (aOR, 1.19; 95% CI, 1.07-1.32), 90 days (aOR, 1.27; 95% CI, 1.15-1.41), and 1 year (adjusted hazard ratio, 1.19; 95% CI, 1.11 to 1.28; P < .05 for all).

Conclusions: Our study findings indicate that socioeconomic disparities exist in the procedural choice for patients undergoing AVR. Patients with lower SES had increased odds of undergoing SAVR, as well as increased odds of readmission after SAVR, but not after TAVR, supporting that health inequities exist in the surgical care of socioeconomically disadvantaged patients.

Keywords: aortic valve replacement; socioeconomic determinants; socioeconomic status; surgical aortic valve replacement; transcatheter aortic replacement.