Variation in cardiac procedure use and racial disparity among Veterans Affairs Hospitals

Utilization of the remote monitoring of cardiac implantable electronic devices in a diverse demographic cohort: Insights from a single-center observation

BACKGROUND

Despite its clinical benefits, patient compliance to remote monitoring (RM) of cardiac implantable electronic devices (CIEDs) varies and remains under-studied in diverse populations.

OBJECTIVE

We sought to evaluate RM compliance, clinical outcomes, and identify demographic and socioeconomic factors affecting RM in a diverse urban population in New York.

METHODS

This retrospective cohort study included patients enrolled in CIED RM at Montefiore Medical Center between December 2017 and May 2022. RM compliance was defined as the percentage of days compliant to RM transmission divided by the total prescribed days of RM. Patients were censored when they were lost to follow-up or at the time of death. The cohorts were categorized into low (≤30%), intermediate (31-69%), and high (≥70%) RM compliance groups. Statistical analyses were conducted accordingly.

RESULTS

Among 853 patients, median RM compliance was 55%. Age inversely affected compliance (p < .001), and high compliance was associated with guideline-directed medical therapy (GDMT) usage and implantable cardioverter defibrillator (ICD)/cardiac resynchronization defibrillator (CRTD) devices. The low-compliance group had a higher mortality rate and fewer regular clinic visits (p < .001) than high-compliance group. Socioeconomic factors did not significantly impact compliance, while Asians showed higher compliance compared with Whites (OR 3.67; 95% CI 1.08-12.43; p = .04). Technical issues were the main reason for non-compliance.

CONCLUSION

We observed suboptimal compliance to RM, which occurred most frequently in older patients. Clinic visit compliance, optimal medical therapy, and lower mortality were associated with higher compliance, whereas insufficient understanding of RM usage was the chief barrier to compliance.

Racial Disparity Among Patients Undergoing Surgical Aortic Valve Replacement and Transcatheter Aortic Valve Replacement in the United States

Transcatheter aortic valve replacement (TAVR) has emerged as a minimally invasive alternative to surgical aortic valve replacement (SAVR). However, racial disparities in the utilization of TAVR persist. This meta-analysis attempts to determine whether the prevalence of adverse outcomes (procedure-related complications) represent barriers to the use of TAVR among African Americans (AA). The TAVR cohort consisted of 89.6% Caucasian (C) and 4.7% AA, while the SAVR cohort included 86.9% C and 6.4% AA. The utilization rate (UR) of TAVR was 1.48 and .35 among C and AA, respectively, while the UR of SAVR was 1.44 and .48 among C and AA, respectively. Following TAVR, for AA the odds ratio (OR) was greater for stroke (OR = 1.22, P = .02) and transient ischemic attack (TIA) (OR = 1.57, P < .001) and lower for undergoing the insertion of a permanent pacemaker (OR = .81, P < .001). While there was a significant difference between C and AA in TAVR and SAVR utilization, outcomes between groups following TAVR are comparable; therefore, adverse outcomes do not appear to be a barrier to the use of TAVR among eligible AA.

The racial disparity among post transcatheter aortic valve replacement outcomes: A meta-analysis

Background

Racial disparities have been well described in cardiovascular disease. However, the impact of race on the outcomes post - Transcatheter aortic valve replacement (TAVR) remains unknown.

Objective

We aim to evaluate the disparity among the race (black and white) post - TAVR.

Methods

We systematically searched all electronic databases from inception until September 26, 2022. The primary outcome was in-hospital all-cause mortality, and secondary outcomes was myocardial infarction (MI), acute kidney injury (AKI), permanent pacemaker implantation (PPI) or ICD, stroke, vascular complications, and major bleeding.

Results

A total of three studies with 1,02,009 patients were included in the final analysis. The mean age of patients with white and black patients was 82.65 and 80.45 years, respectively. The likelihood of in-hospital all-cause mortality (OR, 1.01(95 %CI: 0.86-1.19), P = 0.93), stroke (OR, 0.83(95 %CI:0.61-1.13), P = 0.23, I2 = 46.57 %], major bleeding [OR, 1.05(95 %CI:0.92-1.20), P = 0.46), and vascular complications [OR, 0.92(95 %CI:0.81-1.06), P = 0.26), was comparable between white and black patients. However, patients with white race have lower odds of MI (OR, 0.65(95 %CI:0.50-0.84), P < 0.001), and AKI (OR, 0.84(95 %CI:0.74-0.95), P = 0.01) and higher odds of PPI or ICD (OR, 1.16(95 %CI: 1.06-1.27), P < 0.001, I2 = 0 %) compared with black race patients.

Conclusion

Our findings suggest disparity post - TAVR outcomes existed, and black patients are at higher risk of MI and AKI than white patients.Key Clinical Message:•What is already known on this topic: Disparity has been witnessed among patients with cardiovascular disease. However, no studies have drawn a significant association among post-TAVR patients' outcomes•What this study adds: Among patients who underwent TAVR, there is a difference in the adverse outcomes between black and white race patients. White patients have a lower risk of post-procedure MI and AKI compared with Black patients.•How this study might affect research, practice, or policy: These disparities need to be addressed, and proper guidelines need to be made along with engaging patients with better medical infrastructure and treatment options..

Racial and ethnic differences in implantable cardioverter-defibrillator patient selection, management, and outcomes

Racial and ethnic differences in treatment-cardiovascular and otherwise-have been documented in many aspects of the American health care system and can be seen in implantable cardioverter-defibrillator (ICD) patient selection, counseling, and management. ICDs have been demonstrated to be a powerful tool in the prevention of sudden cardiac death, yet uptake across all eligible patients has been modest. Although patients who do not identify as White are disproportionately eligible for ICDs in the United States, they are less likely to see specialists, be counseled on ICDs, and ultimately have an ICD implanted. This review explores racial and ethnic differences demonstrated in ICD patient selection, outcomes including shock effectiveness, and postimplantation monitoring for both primary and secondary prevention devices. It also highlights barriers for uptake at the health system, physician, and patient levels and suggests areas of further research needed to clarify the differences, illuminate the driving forces of these differences, and investigate strategies to address them.

Factors associated with remote monitoring adherence for cardiovascular implantable electronic devices

BACKGROUND

Professional societies strongly recommend remote monitoring (RM) of all cardiac implantable electronic devices, and higher RM adherence is associated with improved patient outcomes. However, adherence with RM is suboptimal.

OBJECTIVE

The purpose of this study was to better understand factors associated with RM adherence.

METHODS

We linked RM data from the Veterans Affairs National Cardiac Device Surveillance Program to clinical data for patients monitored between October 25, 2018, and October 24, 2020. RM adherence was defined as the percentage of days covered by an RM transmission during the study period. Patients were classified into 3 categories: complete (100% of days covered by an RM transmission), intermediate (above median in patients with <100% adherence), and low (below median in patients with <100% adherence) adherence. We used multivariable logistic regression to examine patient, device, and facility characteristics associated with adherence.

RESULTS

In 52,574 patients, average RM adherence was 71.9%. Only 30.9% (16,224) of patients had complete RM adherence. Black or African American patients had a lower odds of complete RM adherence than white patients (odds ratio 0.88; 95% confidence interval 0.82-0.94), and Hispanic or Latino patients had a lower odds of complete RM adherence (odds ratio 0.79; 95% confidence interval 0.70-0.89) than non-Hispanic or Latino patients. Dementia, depression, and posttraumatic stress disorder were associated with a lower odds of RM adherence.

CONCLUSION

There are significant disparities in RM adherence by race, ethnicity, and neuropsychiatric comorbidities. These findings can inform strategies to improve health equity and ensure that all patients with cardiac implantable electronic devices receive the evidence-based clinical benefits of RM.

Utilization of Implantable Cardioverter Defibrillators Among Patients with a Left Ventricular Assist Device: Insights From a National Database

The trends and predictors of implantable cardioverter defibrillator (ICD) use in patients with a durable left ventricular assist device (LVAD) remain uncertain. We used the National Inpatient Sample to identify hospitalizations between 2009 and 2018 in which patients received a new LVAD or had a pre-existing one. Procedure codes were then used to identify hospitalizations in which a new ICD was implanted. In 34,113 hospitalizations for new/replacement LVADs, an ICD was implanted in 1297 (3.8%). The rate of ICD implantation along with an LVAD declined from 2009-2018 (annual percent change: -23.2%; p-trend<0.001). Independent factors associated with concurrent ICD implantation in patients receiving LVAD were younger age, White (compared with Black) race, and in-hospital cardiac arrest. Concurrent ICD implantation was associated with a longer hospital stay (adjusted mean difference: 4.48 days) and higher inflation-adjusted costs (adjusted mean difference: $31,679), but lower in-hospital mortality rates (adjusted odds ratio: 0.29; p<0.001), compared with LVAD placement alone. Amongst 95,583 hospitalizations of patients with a pre-existing LVAD, an ICD was placed in 616 (0.64%). There was no change in the rate of ICD implantation from 2009-2018 in patients with a pre-existing LVAD (annual percent change: -10.34%; p=0.18).

Implantable cardioverter-defibrillator placement among patients with left ventricular ejection fraction ≤35 % at least 40 days after acute myocardial infarction

Background

Implantable cardioverter-defibrillators (ICDs) reduce the risk of sudden cardiac death among patients with persistently reduced (≤35 %) left ventricular ejection fraction (LVEF) at least 40 days following acute myocardial infarction (AMI). Few prior studies have used LVEF measured after the 40-day waiting period to examine primary prevention ICD placement.

Methods

We sought to determine factors associated with ICD placement among patients who met LVEF criteria post-MI within a large integrated health care system in the U.S by conducting a retrospective cohort study of Veteran patients hospitalized for AMI from 2004 to 2017 who had documented LVEF ≤35 % from echocardiograms performed between 40 and 455 (90 days +1 year) days post-MI. We used multivariable logistic regression to examine factors associated with ICD placement.

Results

Of 12,893 patients with LVEF ≤35 % at least 40 days post-MI, 2176 (16.9 %) received an ICD between 91- and 455-days post-MI. Younger age, fewer comorbidities, revascularization with PCI, and greater use of GDMT were associated with increased odds of receiving an ICD. However, half of patients treated with a beta-blocker, ACE inhibitor or angiotensin receptor blocker, and mineralocorticoid receptor antagonist prior to LVEF assessment did not receive an ICD. Eligible Black patients were less likely (odds ratio 0.80, 95 % confidence interval 0.69-0.92) to receive an ICD than White patients.

Conclusion

Many factors affect ICD placement among Veteran patients with a confirmed LVEF ≤35 % at least 40 days post-MI. Greater understanding of factors influencing ICD placement would help clinicians ensure guideline-concordant care.

Racism and Cardiology: A Global Call to Action

Racism and racial bias influence the lives and cardiovascular health of minority individuals. The fact that minority groups tend to have a higher burden of cardiovascular disease risk factors is often a result of racist policies that restrict opportunities to live in healthy neighbourhoods and have access to high-quality education and healthcare. The fact that minorities tend to have the worst outcomes when cardiovascular disease develops is often a result of institutional or individual racial bias encountered when they interact with the healthcare system. In this review, we discuss bias, discrimination, and structural racism from the viewpoints of cardiologists in Canada, the United Kingdom, and the US, and how racial bias impacts cardiovascular care. Finally, we discuss proposals to mitigate the impact of racism in our specialty.

Inequities in Aortic Stenosis and Aortic Valve Replacement Between Black/African-American, White, and Hispanic Residents of Maryland

Background

Racial and ethnic inequities exist in surgical aortic valve replacement for aortic stenosis (AS), and early studies have suggested similar inequities in transcatheter aortic valve replacement.

Methods and Results

We performed a retrospective analysis of the Maryland Health Services Cost Review Commission inpatient data set from 2016 to 2018. Black patients had half the incidence of any inpatient AS diagnosis compared with White patients (incidence rate ratio [IRR], 0.50; 95% CI, 0.48–0.52; P<0.001) and Hispanic patients had one fourth the incidence compared with White patients (IRR, 0.25; 95% CI, 0.22–0.29; P<0.001). Conversely, the incidence of any inpatient mitral regurgitation diagnosis did not differ between White and Black patients (IRR, 1.00; 95% CI, 0.97–1.03; P=0.97) but was significantly lower in Hispanic compared with White patients (IRR, 0.36; 95% CI, 0.33–0.40; P<0.001). After multivariable adjustment, Black race was associated with a lower incidence of surgical aortic valve replacement (IRR, 0.67; 95% CI, 0.55–0.82 P<0.001 relative to White race) and transcatheter aortic valve replacement (IRR, 0.77; 95% CI, 0.65–0.90; P=0.002) among those with any inpatient diagnosis of AS. Hispanic patients had a similar rate of surgical aortic valve replacement and transcatheter aortic valve replacement compared with White patients.

Conclusions

Hospitalization with any diagnosis of AS is less common in Black and Hispanic patients than in White patients. In hospitalized patients with AS, Black race is associated with a lower incidence of both surgical aortic valve replacement and transcatheter aortic valve replacement compared with White patients, whereas Hispanic patients have a similar incidence of both. The reasons for these inequities are likely multifactorial.

Black lives matter … in the cath lab, too! A proposal for the interventional cardiology community to counteract bias and racism

Structural racism in the United States underlies racial disparities in the criminal justice system, in the healthcare system generally, and with regards to the COVID-19 pandemic. In the year 2020, these inequities combined and magnified to such a degree that it left Black Americans and physicians caring for them questioning how much Black lives matter. Academic medical centers and the major cardiology organizations responded to a global call to end racism with bold statements and initiatives. Interventional cardiologists utilize advanced equipment to mechanically treat a wide spectrum of heart problems, yet this technology has not been applied in an equitable manner. Interventional therapies are often underutilized in Blacks, exacerbating healthcare disparities and contributing to the excess cardiovascular morbidity and mortality in these communities. Racial bias, whether intentional, unconscious, systemic, or at the individual level, plays a role in these disparities. Many in the interventional cardiology community aspire to take intentional steps to reduce the impact of bias and racism in our specialty. We discuss several proposals here and provide a "report card" for interventional programs to perform a self-assessment.

African American-Caucasian American differences in aortic valve replacement in patients with severe aortic stenosis

BACKGROUND

Among patients with severe aortic stenosis (AS), there are limited data on aortic valve replacement (AVR), reasons for nonreceipt and mortality by race.

METHODS

Utilizing the Duke Echocardiography Laboratory Database, we analyzed data from 110,711 patients who underwent echocardiography at Duke University Medical Center between 1999 and 2013. We identified 1,111 patients with severe AS who met ≥1 of 3 criteria for AVR: ejection fraction ≤50%, diagnosis of heart failure, or need for coronary artery bypass surgery. Logistic regression models were used to assess the association between race, AVR and 1-year mortality. χ2 testing was used to assess potential racial differences in reasons for AVR nonreceipt.

RESULTS

Among the 1,111 patients (143 AA and 968 CA) eligible for AVR, AA were more often women, had more diabetes, renal insufficiency, aortic regurgitation and left ventricular hypertrophy. CA were more often smokers, had more ischemic heart disease, hyperlipidemia and higher median income levels. There were no racial differences in surgical risk utilizing logistic euroSCORES. Relative to CA, AA had lower rates of AVR (adjusted odds ratio 0.46, 95% CI 0.3-0.71, P < .001) yet similar 1-year mortality (aHR 0.81, 95% CI 0.57-1.17, P = .262). There were no significant differences in reasons for AVR nonreceipt.

CONCLUSIONS

We identified 143 African Americans (AA) and 968 Caucasian Americans(CA) with severe AS who met prespecified criteria for AVR.. AA relative to CA were more often women, had more diabetes, renal insufficiency, and left ventricular hypertrophy, however had less tobacco use, ischemic heart disease, hyperlipidemia and lower median income levels. Among patients with severe AS, AA relative to CA had lower rates of AVR (adjusted odds ratio 0.46, 95% CI 0.3-0.71, P < .001) without significant differences in reasons for AVR nonreceipt and similar 1-year mortality.

Ethnicity and insurance status predict metastatic disease presentation in prostate, breast, and non-small cell lung cancer

Background

Ethnicity and insurance status have been shown to impact odds of presenting with metastatic cancer, however, the interaction of these two predictors is not well understood. We evaluate the difference in odds of presenting with metastatic disease in minorities compared to white patients despite access to the same insurance across three common cancer types.

Methods

Using the National Cancer Database, a multilevel logistic regression model that estimated the odds of metastatic disease was fit, adjusting for covariates including year of diagnosis, ethnicity, insurance, income, and region. We included adults diagnosed with metastatic prostate, non–small cell lung cancer (NSCLC), and breast cancer from 2004 to 2015.

Results

The study cohort consisted of 1 191 241 prostate cancer (PCa), 1 310 986 breast cancer (BCa), and 1 183 029 NSCLC patients. Private insurance was the most protective factor against metastatic presentation. Odds of presenting with metastatic disease were 0.190 [95% CI, 0.182‐0.198], 0.616 [95% CI, 0.602‐0.630], and 0.270 [95% CI, 0.260‐0.279] for PCa, NSCLC, and BCa compared to uninsured patients, respectively. Private insurance provided the most significant benefit to non‐Hispanic White PCa patients with 81% reduction in odds of metastatic presentation and conferred the least benefit to African‐American NSCLC patients at 30.4% reduction in odds of metastatic presentation.

Conclusions

Insurance status provided the single most protective effect against metastatic presentation. This benefit varied for minorities despite similar insurance. Reducing metastatic disease presentation rates requires addressing social barriers to care independent of insurance.

Impact of Transcatheter Aortic Valve Replacement on Risk Profiles of Surgical Aortic Valve Replacement Patients

BACKGROUND

The advent of transcatheter aortic valve replacement (TAVR) has changed which patients undergo surgical aortic valve replacement (SAVR). We sought to understand the impact of TAVR on the characteristics of SAVR patients in the United States.

METHODS

A cohort of 2959 patients who underwent isolated SAVR at 11 US hospitals that perform both TAVR and SAVR from 2013 through 2017 were grouped by the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database version (v)2.73 (2011-2014), v2.81 (2014-2017), and v2.9 (2017) to assess temporal trends in patient characteristics.

RESULTS

Over time, SAVR patients were younger with fewer preoperative comorbidities. There was a significant decrease in median STS predicted risk of mortality (PROM) score (2.0 vs. 1.8 vs. 1.3, p < 0.001, in v2.73 vs. v2.81 vs. v2.9). Specifically, there were fewer high-risk (STS PROM > 8%: 4.3% vs. 4.7% vs. 1.2%, p = 0.03) and intermediate-risk (STS PROM 4% to 8%: 16.3% vs. 11.7% vs. 4.3%, p < 0.001) patients. The proportion of patients with bicuspid aortic valve disease increased significantly (11.2% vs. 26.9% vs. 36.6%, p < 0.001). There were no differences in operative mortality (1.9% vs. 2.1% vs. 1.4%, p = 0.75).

CONCLUSIONS

The introduction of TAVR has already impacted the demographics, clinical characteristics and risk profiles of patients undergoing SAVR in the US. Now that TAVR is approved for low-risk patients, SAVR is likely to be reserved for younger patients who are willing to receive a mechanical valve and for patients with aortopathy, coronary artery disease, or concomitant mitral or tricuspid pathology.

Quality Measures, All-Cause Mortality, and Health Care Use in a National Cohort of Veterans With Cirrhosis

Decompensated cirrhosis is associated with high morbidity and mortality. However, no standardized quality measures (QMs) have yet been adopted widely. The Veterans Affairs (VA) Advanced Liver Disease Technical Advisory Group recently developed a set of six internal QMs to guide quality improvement efforts in cirrhosis in the domains of access to care, hepatocellular carcinoma surveillance, variceal surveillance, quality of inpatient care for upper gastrointestinal bleeding, and cirrhosis-related rehospitalizations. We aimed to (1) quantify adherence to cirrhosis QMs and (2) determine whether adherence was associated with all-cause mortality and health care use within a large national cohort of veterans with cirrhosis. We performed a retrospective study using data from the Veterans Outcomes and Costs Asociated with Liver Disease cohort of 121,129 patients newly diagnosed with cirrhosis from January 1, 2008, to December 31, 2016, at 128 VA facilities. The mean follow-up time was 2.7 years (interquartile range, 1.1-5.1 years). Adherence to outpatient access to specialty care was 71%, variceal surveillance was 32%, and early postdischarge care was 54%. In adjusted analyses, outpatient access to specialty care (hazard ratio [HR], 0.80; 95% confidence interval [CI], 0.78-0.82), hepatocellular carcinoma surveillance (HR, 0.92; 95% CI, 0.90-0.95), variceal surveillance (HR, 0.93; 95% CI, 0.89-0.99), and early postdischarge care (HR, 0.57; 95% CI, 0.54-0.60) were associated with lower all-cause mortality. Readmissions after 30 days (HR, 1.53; 1.46-1.60) and 90 days (HR, 1.88; 95% CI, 1.54-1.70) were associated with higher all-cause mortality. Higher adherence to QMs was also associated with lower inpatient health care use. Conclusion: Five of the six proposed VA cirrhosis QMs were measurable using existing data sources, associated with mortality and health care use, and may be used to guide future quality improvement efforts in cirrhosis.

Ethnic and Gender Disparities in the Uptake of Transcatheter Aortic Valve Replacement in the United States

INTRODUCTION

Little is known about ethnic and gender disparities for transcatheter aortic valve replacement (TAVR) procedures in the United States.

METHODS

We queried the Nationwide Inpatient Sample (NIS) database (2011-2014) to identify patients who underwent TAVR. We described the temporal trends in the uptake of TAVR procedures among various ethnicities and genders.

RESULTS

Our analysis identified 39,253 records; 20,497 (52.2%) were men and 18,756 (47.8%) were women. Among all TAVRs, 87.2% were Caucasians, 3.9% were African Americans (AA), 3.7% were Hispanics, and 5.2% were of other ethnicities. We found a significant rise in the trend of TAVRs in all groups: in Caucasian men (coefficient = 0.946, p < 0.001), Caucasian women (coefficient = 0.985, p < 0.001), AA men (coefficient = 0.940, p < 0.001), AA women (coefficient = 0.864, p < 0.001), Hispanic men (coefficient = 0.812, p = 0.001), Hispanic women (coefficient = 0.845, p < 0.001). Hence, the uptrend was most significant among Caucasian women, and relatively least significant among Hispanic men. Multivariate regression analysis was conducted to evaluate in-hospital mortality among different groups after adjusting for demographics and baseline characteristics. After multivariable regression for baseline characteristics overall, the in-hospital mortality per 100 TAVRs was highest among Hispanic men 5.5%, followed by Caucasian women 5.0%, Hispanic women 4.6%, AA women 3.7%, AA men 3.4%, and Caucasian men 3.38% (adjusted p value = 0.004).

CONCLUSIONS

In this observational study, we demonstrated that there is evidence of ethnic and gender differences in the overall uptake and adjusted mortality of TAVRs in the United States.

Racial and sex disparities in resource utilization and outcomes of multi-vessel percutaneous coronary interventions (a 5-year nationwide evaluation in the United States)

Background

There is a paucity of data regarding the racial and sex disparities in the outcomes of multi-vessel percutaneous coronary interventions (MVPCI).

Methods

The National Inpatient Sample (NIS) was examined for the years 2010 to 2014 to incorporate adult MVPCI-related hospitalizations using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) procedure codes. We excluded patients with the missing race or gender data from the final scrutiny. Discharge weights were used to obtain the national estimations. The principal outcomes were MVPCI-related racial and gender disparities in terms of the in-hospital mortality and complications, and diagnostic and therapeutic healthcare resource utilization. Secondary outcomes were the length of hospital stay (LOS) and hospitalization charges. We used the Chi-square test and t-test/ANOVA test to equate dichotomous and continuous variables respectively. A two-tailed P of <0.05 was considered clinically significant.

Results

An estimated 769,502 MVPCI-related hospitalizations were recorded from 2010 to 2014 after excluding patients with the missing data (70,954; 8.4%). Black male and female were the youngest (62±13, 64±14 years). The highest non-elective admissions (M: 72.8%, F: 71.2%) were reported among Hispanics. Non-whites showed a higher proportion of comorbidities with lower resource utilization than whites. Hispanic males (OR 1.23) showed the highest odds of the in-hospital mortality whereas among females, Asians (OR 1.51), blacks (OR 1.35), followed by Hispanics (OR 1.22) revealed higher odds of in-hospital mortality. Odds of cardiac complications were highest amongst Asians (M: OR 1.19, F: OR 1.40). Black (6±8 days) and Hispanic (7±9 days) showed the highest length of stay among males and females respectively. Total hospitalization charges were highest among Asians. There was a greater increase in the all-cause mortality in non-whites from 2010 to 2014.

Conclusions

This study determines the existence of racial disparities in resource utilization and outcomes in MVPCI. There is an instant need for interventions designed to govern these healthcare discrepancies.

Associations between Race/Ethnicity, Uterine Fibroids, and Minimally Invasive Hysterectomy in the VA Healthcare System

BACKGROUND

In the general population, Black and Latina women are less likely to undergo minimally invasive hysterectomy than White women, which may be related to racial/ethnic variation in fibroid prevalence and characteristics. Whether similar differences exist in the Department of Veterans Affairs Healthcare System (VA) is unknown.

METHODS

Using VA clinical and administrative data, we identified all women veterans undergoing hysterectomy for benign indications in fiscal years 2012-2014. We identified hysterectomy route (laparoscopic with/without robot-assist, vaginal, abdominal) by International Classification of Diseases, 9th edition, codes. We used multinomial logistic regression to estimate associations of race/ethnicity with hysterectomy route and tested whether associations varied by fibroid diagnosis using an interaction term. Models adjusted for age, income, body mass index, gynecologic diagnoses, medical comorbidities, whether procedure was performed or paid for by VA, geographic region, and fiscal year.

RESULTS

Among 2,744 identified hysterectomies, 53% were abdominal, 29% laparoscopic, and 18% vaginal. In multinomial models, racial/ethnic differences were present among veterans with but not without fibroid diagnoses (p value for interaction < .001). Among veterans with fibroids, Black veterans were less likely than White veterans to have minimally invasive hysterectomy (laparoscopic vs. abdominal relative risk ratio [RRR], 0.52; 95% CI, 0.38-0.72; vaginal vs. abdominal RRR, 0.58; 95% CI, 0.43-0.73). Latina veterans were as likely as White veterans to have laparoscopic as abdominal hysterectomy (RRR, 1.34; 95% CI, 0.87-2.07) and less likely to have vaginal than abdominal hysterectomy (RRR, 0.32; 95% CI, 0.15-0.69).

CONCLUSIONS

Receipt of minimally invasive hysterectomy among women veterans with fibroids varied by race/ethnicity. Further investigation of the underlying mechanisms and potential interventions to increase minimally invasive hysterectomy among minority women veterans is needed.

Outcomes of Care for Ischemic Heart Disease and Chronic Heart Failure in the Veterans Health Administration

Importance

The Department of Veterans Affairs (VA) operates a nationwide system of hospitals and hospital-affiliated clinics, providing health care to more than 2 million veterans with cardiovascular disease. While data permitting hospital comparisons of the outcomes of acute cardiovascular care (eg, myocardial infarction) are publicly available, little is known about variation across VA medical centers (VAMCs) in outcomes of care for populations of patients with chronic, high-risk cardiovascular conditions.

Objective

To determine whether there are substantial differences in cardiovascular outcomes across VAMCs.

Design, Setting, and Participants

Retrospective cohort study comprising 138 VA hospitals and each hospital's affiliated outpatient clinics. Patients were identified who received VA inpatient or outpatient care between 2010 and 2014. Separate cohorts were constructed for patients diagnosed as having either ischemic heart disease (IHD) or chronic heart failure (CHF). The data were analyzed between June 24, 2015, and November 21, 2017.

Exposures

Hierarchical linear models with VAMC-level random effects were estimated to compare risk-standardized mortality rates for IHD and for CHF across 138 VAMCs. Mortality estimates were risk standardized using a wide array of patient-level covariates derived from both VA and Medicare health care encounters.

Main Outcomes and Measures

All-cause mortality.

Results

The cohorts comprised 930 079 veterans with IHD and 348 015 veterans with CHF; both cohorts had a mean age of 77 years and were predominantly white (IHD, n = 822 665 [89%] and CHF, n = 287 871 [83%]) and male (IHD, n = 916 684 [99%] and CHF n = 341 352 [98%]). The VA-wide crude annual mortality rate was 7.4% for IHD and 14.5% for CHF. For IHD, VAMCs' risk-standardized mortality varied from 5.5% (95% CI, 5.2%-5.7%) to 9.4% (95% CI, 9.0%-9.9%) (P < .001 for the difference). For CHF, VAMCs' risk-standardized mortality varied from 11.1% (95% CI, 10.3%-12.1%) to 18.9% (95% CI, 18.3%-19.5%) (P < .001 for the difference). Twenty-nine VAMCs had IHD mortality rates that significantly exceeded the national mean, while 35 VAMCs had CHF mortality rates that significantly exceeded the national mean. Veterans Affairs medical centers' mortality rates among their IHD and CHF populations were not associated with 30-day mortality rates for myocardial infarction (R2 = 0.01; P = .35) and weakly associated with hospitalized heart failure 30-day mortality (R2 = 0.16; P < .001) and the VA's star rating system (R2 = 0.06; P = .005).

Conclusions and Relevance

Risk-standardized mortality rates for IHD and CHF varied widely across the VA health system, and this variation was not well explained by differences in demographics or comorbidities. This variation may signal substantial differences in the quality of cardiovascular care between VAMCs.

A review of racial disparities in transcatheter aortic valve replacement (TAVR): accessibility, referrals and implantation

Racial disparities in transcatheter aortic valve replacement (TAVR) implantation results from several factors, including socioeconomic disparities, inherent biases in healthcare provision, fewer referrals to specialists and language barriers in some minority populations. In this review article, we discuss the current data on the racial disparities in TAVR, explore the prevalence of aortic stenosis in different demographics in the United States and we proffer practical solutions to these problems.

Race and Sex Differences in Post-Myocardial Infarction Angina Frequency and Risk of 1-Year Unplanned Rehospitalization

BACKGROUND

Race and sex disparities in in-hospital treatment and outcomes of patients with acute myocardial infarction (MI) have been described, but little is known about race and sex differences in post-MI angina and long-term risk of unplanned rehospitalization. We examined race and sex differences in post-MI angina frequency and 1-year unplanned rehospitalization to identify factors associated with unplanned rehospitalization, testing for whether race and sex modify these relationships.

METHODS

Using TRANSLATE-ACS (Treatment With Adenosine Diphosphate Receptor Inhibitors: Longitudinal Assessment of Treatment Patterns and Events after Acute Coronary Syndrome) data, we examined 6-week and 1-year angina frequency and 1-year unplanned rehospitalization stratified by race and sex among MI patients treated with percutaneous coronary intervention. We used multivariable logistic regression to assess factors associated with unplanned rehospitalization and tested for interactions among angina frequency, race, and sex.

RESULTS

A total of 11 595 MI patients survived to 1 year postdischarge; there were 66.6% white male patients, 24.3% white female patients, 5.3% black male patients, and 3.8% black female patients. Overall, 29.7% had angina at 6 weeks, and 20.6% had angina at 1 year postdischarge. Relative to white patients, black patients were more likely to have angina at 6 weeks (female: 44.2% versus 31.8%; male: 33.5% versus 27.1%; both P<0.0001) and 1 year (female: 49.4% versus 38.9%; male: 46.3% versus 31.1%; both P<0.0001). Rates of 1-year unplanned rehospitalization were highest among black female patients (44.1%), followed by white female patients (38.4%), black male patients (36.4%), and white male patients (30.2%, P<0.0001). In the multivariable model, 6-week angina was most strongly associated with unplanned rehospitalization (hazard ratio, 1.49; 95% confidence interval, 1.36-1.62; P<0.0001); this relationship was not modified by race or sex (adjusted 3-way P_interaction=0.41).

CONCLUSIONS

One-fifth of MI patients treated with percutaneous coronary intervention report 1-year postdischarge angina, with black and female patients more likely to have angina and to be rehospitalized. Better treatment of post-MI angina may improve patient quality of life and quality of care and help to lower rates of rehospitalization overall and particularly among black and female patients, given their high prevalence of post-MI angina.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT01088503.

Methods for Measuring Racial Differences in Hospitals Outcomes Attributable to Disparities in Use of High-Quality Hospital Care

OBJECTIVE

To compare two approaches to measuring racial/ethnic disparities in the use of high-quality hospitals.

DATA SOURCES

Simulated data.

STUDY DESIGN

Through simulations, we compared the "minority-serving" approach of assessing differences in risk-adjusted outcomes at minority-serving and non-minority-serving hospitals with a "fixed-effect" approach that estimated the reduction in adverse outcomes if the distribution of minority and white patients across hospitals was the same. We evaluated each method's ability to detect and measure a disparity in outcomes caused by minority patients receiving care at poor-quality hospitals, which we label a "between-hospital" disparity, and to reject it when the disparity in outcomes was caused by factors other than hospital quality.

PRINCIPAL FINDINGS

The minority-serving and fixed-effect approaches correctly identified between-hospital disparities in quality when they existed and rejected them when racial differences in outcomes were caused by other disparities; however, the fixed-effect approach has many advantages. It does not require an ad hoc definition of a minority-serving hospital, and it estimated the magnitude of the disparity accurately, while the minority-serving approach underestimated the disparity by 35-46 percent.

CONCLUSIONS

Researchers should consider using the fixed-effect approach for measuring disparities in use of high-quality hospital care by vulnerable populations.

Racial/Ethnic Disparities in VA Services Utilization as a Partial Pathway to Mortality Differentials Among Veterans Diagnosed With TBI

Objective:

Primary: To examine Veterans Administration (VA) utilization and other potential mediators between racial/ethnic differentials and mortality in veterans diagnosed with traumatic brain injury (TBI).

Design:

A national cohort of veterans clinically diagnosed with TBI in 2006 was followed from January 1, 2006 through December 31, 2009 or until date of death. Utilization was tracked for 12 months. Differences in survival and potential mediators by race were examined via K-Wallis and chi-square tests. Potential mediation of utilization in the association between mortality and race/ethnicity was studied by fitting Cox models with and without adjustment for demographics and co-morbidities. Poisson regression was used to study the association of race/ethnicity with utilization of specialty services potentially important in the management of TBI.

Setting:

United States (US) Veterans Administration (VA) Hospitals and Clinics.

Participants:

14, 690 US veterans clinically diagnosed with TBI in 2006.

Interventions:

Not Applicable. The study is a secondary data analysis.

Main Outcome Measures:

Mortality, Utilization.

Results:

Hispanic veterans were found to have significantly higher unadjusted mortality (6.69%) than Non-Hispanic White veterans (2.93%). Hispanic veterans relative to Non-Hispanic White were found to have significantly lower utilization of all services examined, except imaging. Neurology was found to be the utilization mediator with the highest percent of excess risk (3.40%) while age was the non utilization confounder with the highest percent of excess risk (31.49%). In fully adjusted models for demographics and co-morbidities, Hispanic veterans relative to Non-Hispanic Whites were found to have less total visits (IRR 0.89), TBI clinic (IRR 0.43), neurology (IRR 0.35), rehabilitation (IRR 0.37), and other visits (IRR 0.85) with only higher mental health visits (IRR 1.53).

Conclusions:

We found evidence that utilization is a partial mediator between race/ethnicity and mortality, especially neurology utilization. We also found that Hispanic veterans receive significantly less TBI clinic, neurology, rehabilitation and other types of utilization. The use of innovative system factors (decision aids, information tools, patient activation, and adherence support interventions) could be valuable in enhancing utilization of specific TBI related services, especially among ethnic minorities.

Racial differences in withdrawal of mechanical ventilation do not alter mortality in neurologically injured patients

PURPOSE

Racial differences in withdrawal of mechanical ventilation (WMV) have been demonstrated among patients with severe neurologic injuries. We ascertained whether such differences might be accounted for by imbalances in socioeconomic status or disease severity, and whether such racial differences impact hospital mortality or result in greater discharge to long-term care facilities.

MATERIALS AND METHODS

We evaluated WMV among 1885 mechanically ventilated patients with severe neurologic injury (defined as Glasgow Coma Scale <9), excluding those progressing to brain death within the first 48 hours.

RESULTS

Withdrawal of mechanical ventilation was less likely in nonwhite patients (22% vs 31%, P < .001). Nonwhites were younger and were more likely to have Medicaid or no insurance, live in ZIP codes with low median household incomes, be unmarried, and have greater illness severity; but after adjustment for these variables, racial difference in WMV persisted (odds ratio, 0.56; 95% confidence interval, 0.42-0.76). Nonwhite patients were more likely to die instead with full support or progress to brain death, resulting in equivalent overall hospital mortality (40% vs 42%, P = .44). Among survivors, nonwhites were more likely to be discharged to long-term care facilities (27% vs 17%, P < .001).

CONCLUSIONS

Surrogates of nonwhite neurologically injured patients chose WMV less often even after correcting for socioeconomic status and other confounders. This difference in end-of-life decision making does not appear to alter hospital mortality but may result in more survivors left in a disabled state.

Racial differences in rates of aortic valve replacement in patients with severe aortic stenosis

Racial disparities exist in the treatment of many cardiovascular diseases. Aortic valve replacement (AVR) is the only treatment for aortic stenosis (AS) that improves patient symptoms and survival. To date, no studies have compared the rate of AVR among different races. The records of patients with an aortic valve area <1 cm(2) by echocardiography diagnosed between January 2004 and May 2010 at Barnes-Jewish Hospital were reviewed retrospectively. Patients were stratified by race. Of the 880 patients analyzed, 10% were African American (AA), and 90% were European American (EA). AA more frequently had hypertension (82% vs 67%, p <0.01), diabetes mellitus (45% vs 32%, p = 0.02), chronic kidney disease (28% vs 17%, p = 0.01), and end stage renal disease (18% vs 2%, p <0.001). AA underwent AVR less frequently than EA (39% vs 53%, p = 0.02) and refused intervention more often (33% vs 20%, p = 0.04). When treated, AA and EA had similar 3-year survival (49% [38 to 60] vs 50% [45 to 54], p = 0.31). Identification of the factors associated with treatment refusal would further our ability to counsel patients on the decision to pursue AVR.

Disparities in revascularization rates after acute myocardial infarction between aboriginal and non-aboriginal people in Australia

BACKGROUND

This study examined revascularization rates after acute myocardial infarction (AMI) for Aboriginal and non-Aboriginal patients sequentially controlling for admitting hospital and risk factors.

METHODS AND RESULTS

Hospital data from the state of New South Wales, Australia (July 2000 through December 2008) were linked to mortality data (July 2000 through December 2009). The study sample were all people aged 25 to 84 years admitted to public hospitals with a diagnosis of AMI (n=59 282). Single level and multilevel Cox regression was used to estimate rates of revascularization within 30 days of admission. A third (32.9%) of Aboriginal AMI patients had a revascularization within 30 days compared with 39.7% non-Aboriginal patients. Aboriginal patients had a revascularization rate 37% lower than non-Aboriginal patients of the same age, sex, year of admission, and AMI type (adjusted hazard ratio, 0.63; 95% confidence interval, 0.57-0.70). Within the same hospital, however, Aboriginal patients had a revascularization rate 18% lower (adjusted hazard ratio, 0.82; 95% confidence interval, 0.74-0.91). Accounting for comorbidities, substance use and private health insurance further explained the disparity (adjusted hazard ratio, 0.96; 95% confidence interval, 0.87-1.07). Hospitals varied markedly in procedure rates, and this variation was associated with hospital size, remoteness, and catheterization laboratory facilities.

CONCLUSIONS

Aboriginal Australians were less likely to have revascularization procedures after AMI than non-Aboriginal Australians, and this was largely explained by lower revascularization rates at the hospital of first admission for all patients admitted to smaller regional and rural hospitals, a higher comorbidity burden for Aboriginal people, and to a lesser extent a lower rate of private health insurance among Aboriginal patients.

Racial and ethnic disparities in the surgical treatment of acute myocardial infarction: the role of hospital and physician effects

Many studies document disparities between Blacks and Whites in the treatment of acute myocardial infarction on controlling for patient demographic factors and comorbid conditions. Other studies provide evidence of disparities between Hispanics and Whites in cardiac care. Such disparities may be explained by differences in the hospitals where minority and nonminority patients obtain treatment and by differences in the traits of physicians who treat minority and nonminority patients. We used 1997-2005 Florida hospital inpatient discharge data to estimate models of cardiac catheterization, percutaneous transluminal coronary angioplasty, and coronary artery bypass grafting in Medicare fee-for-service patients 65 years and older. Controlling for hospital fixed effects does not explain Black-White disparities in cardiac treatment but largely explains Hispanic-White disparities. Controlling for physician fixed effects accounts for some extent of the racial disparities in treatment and entirely explains the ethnic disparities in treatment.

Hospital racial composition and the treatment of localized prostate cancer

BACKGROUND

Racial differences in the treatment of men with localized prostate cancer remain poorly understood. This study examines whether hospital racial composition is associated with the type of treatment black and white men receive.

METHODS

The authors performed a retrospective cohort study of men in Surveillance, Epidemiology, and End Results-Medicare diagnosed with localized prostate cancer from 1995 to 2005 linked to hospital and census data. A total of 134,291 men were assigned to the hospital where they received care. Generalized estimating equations were used to determine whether hospital racial composition was associated with the receipt of definitive therapy and type of treatment.

RESULTS

Black men were less likely to receive radiation and/or prostatectomy compared with white men (55.5% vs 63.7%, P < .001) and, among those who received definitive therapy, were less likely to undergo prostatectomy (27.5% vs 31.9%, P < .001). The percentage of black men who received their care at hospitals with a high proportion of black patients was 48.0%, compared with only 5.2% of white patients who received care in this subset of hospitals. Men were significantly less likely to receive definitive treatment (odds ratio, 0.81; 95% confidence interval, 0.74-0.90) in hospitals with a high proportion of black patients compared with men seen at hospitals with fewer black patients. The association between hospital racial composition and treatment did not significantly differ by patient race.

CONCLUSIONS

Hospital racial composition is consistently associated with the care that men receive for localized prostate cancer. Better understanding of the factors that determine where men receive care is an important component in reducing variation in treatment.

Low referral pattern for implantable defibrillator therapy in a tertiary hospital: referral physician survey and Monte Carlo simulation

Although implantable cardioverter defibrillator (ICD) therapy is the standard of care for prevention of sudden cardiac death (SCD), its underutilization is a clinical concern. We performed a retrospective study on patients who underwent cardiac catheterization at a tertiary medical center to identify those who were eligible for ICD therapy as per the guidelines and those who actually received it as a part of treatment. Surprisingly, only 4.4% of eligible patients received ICD for SCD prevention. Assuming that the major cause of this underutilization of ICD therapy was low referral, we performed a structured survey among the referring physicians to assess specialists' availability, primary care physicians' role in ICD referral, patient management concerns, familiarity with ICD guidelines, and economics of ICD implantation. Physician response rate of the survey was 51% (35/68). Survey results showed that the common reasons for underreferral included nonavailability of electrophysiologists (34%), poor quality of life of patients (25.7%), patients not being on optimal therapy (25.7%), and low awareness (22.85%). Subsequently, a Monte Carlo simulation was used to assess a hypothetical survival of the study cohort, which showed that in an "ideal scenario" of ICD implantation, the mortality in the study cohort was decreased by 6.9% and 12.3% at 2- and 5-year follow-up, respectively. This study highlights the underutilization of ICDs and the referring physicians' approach to this therapy.

Are providers more likely to contribute to healthcare disparities under high levels of cognitive load? How features of the healthcare setting may lead to biases in medical decision making

Systematic reviews of healthcare disparities suggest that clinicians' diagnostic and therapeutic decision making varies by clinically irrelevant characteristics, such as patient race, and that this variation may contribute to healthcare disparities. However, there is little understanding of the particular features of the healthcare setting under which clinicians are most likely to be inappropriately influenced by these characteristics. This study delineates several hypotheses to stimulate future research in this area. It is posited that healthcare settings in which providers experience high levels of cognitive load will increase the likelihood of racial disparities via 2 pathways. First, providers who experience higher levels of cognitive load are hypothesized to make poorer medical decisions and provide poorer care for all patients, due to lower levels of controlled processing (H1). Second, under greater levels of cognitive load, it is hypothesized that healthcare providers' medical decisions and interpersonal behaviors will be more likely to be influenced by racial stereotypes, leading to poorer processes and outcomes of care for racial minority patients (H2). It is further hypothesized that certain characteristics of healthcare settings will result in higher levels of cognitive load experienced by providers (H3). Finally, it is hypothesized that minority patients will be disproportionately likely to be treated in healthcare settings in which providers experience greater levels of cognitive load (H4a), which will result in racial disparities due to lower levels of controlled processing by providers (H4b) and the influence of racial stereotypes (H4c).The study concludes with implications for research and practice that flow from this framework.

Racial and ethnic disparities in the VA health care system: a systematic review

OBJECTIVES

To better understand the causes of racial disparities in health care, we reviewed and synthesized existing evidence related to disparities in the "equal access" Veterans Affairs (VA) health care system.

METHODS

We systematically reviewed and synthesized evidence from studies comparing health care utilization and quality by race within the VA.

RESULTS

Racial disparities in the VA exist across a wide range of clinical areas and service types. Disparities appear most prevalent for medication adherence and surgery and other invasive procedures, processes that are likely to be affected by the quantity and quality of patient-provider communication, shared decision making, and patient participation. Studies indicate a variety of likely root causes of disparities including: racial differences in patients' medical knowledge and information sources, trust and skepticism, levels of participation in health care interactions and decisions, and social support and resources; clinician judgment/bias; the racial/cultural milieu of health care settings; and differences in the quality of care at facilities attended by different racial groups.

CONCLUSIONS

Existing evidence from the VA indicates several promising targets for interventions to reduce racial disparities in the quality of health care.