TEVAR More Common Among Minorities, Lower Income Patients

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Contrary to previous research, racial minorities and patients with lower socioeconomic status are more likely to receive thoracic endovascular aortic repair (TEVAR) than open surgery, according to results from a national registry study published online July 30, 2013, ahead of print in the Journal of Vascular Surgery.

Researchers led by Gorav Ailawadi, MD, of the University of Virginia (Charlottesville, VA), looked at 60,784 patients from the Nationwide Inpatient Sample who received TEVAR or open surgical repair from 2005 to 2008, stratifying patients by race and socioeconomic status/income. The assumption going in was that racial minorities and those with lower income levels would have less access to the more recent endovascular technology than whites and patients with higher socioeconomic status.

Over three-fourths of patients (79.4%) underwent open repair. Patients receiving TEVAR were more likely to be older, female, and have more comorbidities. They were also more likely to have Medicare insurance, whereas the most common payer status for open repair was private insurance.

Non-White, Lower-Income Patients Show Higher TEVAR Rates

Over one-fourth (26.3%) of TEVAR patients were non-white compared with 20.6% of open repair patients (P < 0.001). In addition, 28.6% of African-American patients received TEVAR, compared with only 19.5% of white patients (P < 0.001). With regard to socioeconomic status, more patients in the lowest income quartile received TEVAR compared with patients in the highest quartile (23.7% vs. 16.7%; P < 0.001).

For all races and socioeconomic quartiles, thoracic aortic aneurysms were more common than aortic dissections (P < 0.001). While the volume of open repairs remained relatively stable over the study period, the number of TEVAR procedures increased drastically following US Food and Drug Administration approval of the procedure in 2005. The majority of patients undergoing either open repair or TEVAR were treated at very high-volume hospitals (77% and 80%,, respectively). Interestingly, hospitals with lower overall thoracic aortic repair volumes did not treat a higher proportion of racial minority patients.

Total length of stay, charges, and mortality were lower with TEVAR (table 1).

Table 1. In-Hospital Outcomes, Costs

On logistic regression analysis controlling for multiple patient comorbidities and hospital factors, African-American and Hispanic patients were 71% and 70% more likely than whites to receive TEVAR, respectively. Native Americans, although representing a small portion of patients, were more than twice as likely to receive TEVAR as whites. Meanwhile, the odds of receiving TEVAR for patients in the lowest income quartile were 24% greater than for those in the highest income quartile. In fact, the propensity to be treated with TEVAR increased in proportion to decreasing income status (table 2).

Table 2. TEVAR Based on Race and Socioeconomic Status

“These findings regarding treatment allocation for thoracic aortic disease counter the racial and socioeconomic inequalities that have been described in the quality of patient care and the allocation of endovascular repair for abdominal aortic aneurysms,” the authors state. “TEVAR has similarly defied other established health care relationships, such as the relationship between procedure volume and outcome and between race and mortality.”

Dr. Ailawadi and colleagues add that TEVAR outcomes in the study did not appear to differ according to hospital volume level.

They note that differences in disease severity may help explain some of the increased association between TEVAR and racial minorities as well as lower income patients. For instance, racial minorities and low-income patients often present with more severe symptoms requiring emergent repair. In the present study, TEVAR patients were more likely to have ruptured thoracic aortic aneurysms (5.3% vs. 2.3% treated with open surgical repair; P < 0.001).

“These individual differences may play a role in the treatment selection and may partially explain the increased performance of TEVAR,” the authors note.

Medicare Status, Lack of Volume-Outcome Relationship Possible Explanations

So may payer status, Dr. Ailawadi and colleagues add. TEVAR patients, they observe, were more likely to be Medicare recipients, who are typically older or have end-stage renal disease, thereby increasing their comorbidities. “As a result,” the authors note, “more Medicare patients may not have been appropriate candidates for open repair and were therefore treated with TEVAR.”

In an interview with TCTMD, Philip P. Goodney, MD, MS, of Dartmouth-Hitchcock Medical Center (Lebanon, NH), noted that the study “does seem kind of contrary [to expectations] because you usually think newer technologies are often steered away from disadvantaged populations.”

He referenced the example of current-generation coronary stents, which “didn’t necessarily disseminate quickly in disadvantaged populations, so one would think that TEVAR would follow the same pattern, but it turned out to be just the opposite.”

In addressing this seeming contradiction, Dr. Goodney explained that previously “it may have been possible that disadvantaged populations may not have received treatment at all for a complex condition such as thoracic aortic aneurysm.  However, when this new treatment evolves, TEVAR, it is technically simpler than open repair and can be offered in broader settings. So hospitals that couldn’t necessarily do a [complex] aneurysm can probably offer patients a straightforward TEVAR. Now all of a sudden there are settings where patients have new avenues for treatment.”

And the patients most likely to benefit are minorities and lower income patients, Dr. Goodney observed. “In our work, we found that the volume-outcome relationship that was quite prominent for open surgical repair—meaning if you had complex aortic surgery in a low-volume hospital, you’re going to do pretty poorly—that relationship strongly favored white or high socioeconomic status patients,” Dr. Goodney said. “But interestingly, we found that the same relationship didn’t hold for TEVAR. TEVAR has been widely disseminated over the last several years, so those patients who didn’t have a high-volume, high-performing hospital where they could undergo open repair now have a good option for endovascular repair. It seems that these changes have benefitted African-American and low socioeconomic patients. It’s a good news story for a change.”

Source:

Johnston WF, LaPar DJ, Newhook TE, et al. Association of race and socioeconomic status with the use of endovascular repair to treat thoracic aortic diseases. J Vasc Surg. 2013;Epub ahead of print.

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