Socioeconomic Disparities In Care Following Transcatheter Aortic Valve Replacement

D. Ahmad¹, C. E.. Diaz-Castrillon¹, Y. Wang², F. Thoma², D. Serna-Gallegos², D. Kliner¹, C. Toma¹, D. West³, A. Makani¹, I. Sultan^2
1University of Pittsburgh, Pittsburgh, Pennsylvania ²University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania ³University of Pittsburgh, Latrobe, Pennsylvania

Purpose: Knowledge of disparities in access to transcatheter aortic valve replacement (TAVR) is growing; however, not much is known about disparities in access to post-TAVR care. We sought to assess the role of socioeconomic factors present at time of TAVR and their impact on healthcare utilization post-TAVR.

Methods: This was a retrospective review of institutional TVT data from 2012 to 2023. Race, income, and area deprivation index (ADI) were considered as socioeconomic predictor variables. Patients were stratified into four groups based on ADI: < 25 (group 1), 25-50 (group 2), 50-75 (group 3), and >75 (group 4). A composite outcome of high resource utilization (HRU) was created which included reintervention for valve dysfunction (transcatheter or surgical), readmission within one year, and office visits >2 in one year. Office visits to Cardiology, Cardiac Surgery, Cardiothoracic Surgery, Emergency Medicine, Family Practice, Geriatrics, Home Health, Internal Medicine, and Physical Medicine and Rehabilitation were considered. All patients who underwent TAVR were included. Those with previous Surgical AVR (SAVR), no income or ADI information, and no follow-up data were excluded. Univariable and multivariable logistic regression analysis were performed to identify predictors of HRU after TAVR

Results: A total of 3194 patients were included of which women comprised 47.7% (1523/3194). Women also comprised the highest proportion of group 4 (50.9% (564/1108)) which also had the highest proportion of black patients (3.07% (34/1108)). The median ADI score was 67 (51-81), indicating moderate-high socioeconomic deprivation in this population. The five-minute walk test>6 seconds (surrogate of frailty) was most prevalent in group 4 (66.4% (736/1108), p< 0.001) as were the lowest quartile score ( < 25%) on the Kansas Cardiomyopathy Questionnaire (KCCQ-12) (20.2% (224/1108), p=0.001) and lowest median household income ($42,540 (37,960-47,400), p< 0.001). Most office visits were to Cardiology (63.8% (1232/1930)) followed by Family Practice (20.5% (395/1930)) and Internal Medicine (13.4% (258/1930).
Overall mortality showed no trend but was different among the groups (group 1: 32% vs. group 2: 34.9% vs. group 3: 38.5% vs. group 4: 32.4%, p=0.05). The composite outcome of HRU was observed most in group 1 and least in group 4 (83.5% vs. 79% vs. 67.8% vs. 66%, p< 0.001). On multivariable regression, ADI group 3 (Odds Ratio (OR): 0.433 (95% confidence interval: 0.271-0.690), p=0.0004) and group 4 (OR: 0.380 (0.237-0.608), p< 0.001) were associated with lower odds of the composite outcome (Table).

Conclusion: The interpretation of HRU is context-dependent but in the setting of high ADI, it most likely reflects reduced access to post-TAVR care and not a lack of need for care. Therefore, it is imperative that patients in high ADI areas be monitored closely and provided equitable access to post-TAVR care

Identify the source of the funding for this research project: No funding