According to a study by The Commonwealth Fund, America ranks last among industrialized countries in measures of health equity and access to care, and has done so each year the study has been published, starting in 2004. Despite clear advancements in technology and delivery of care, accessing these health care innovations remains more of a privilege than a right in the United States.
In the first piece of this ongoing series, we revealed pronounced racial gaps in who has access to surgical care across several widely performed procedures. Another crucial component of assessing disparities in health care is understanding what happens after patients are able to access care. Do different subgroups experience differential treatment once they arrive at the hospital? In order to examine this question, we took a closer look at racial differences in health outcomes for the same eight procedures examined in the first article, focusing on death and unplanned readmission.
After accounting for common comorbidities, we found that there remained an excess risk of mortality among Black patients compared to white patients in six of the eight procedures we rate (Figure 1). The most striking differences are observed in aortic valve surgery and heart bypass surgery, where being Black was associated with 17 and eight more deaths per 1,000 inpatient admissions, respectively. A similar trend can be seen in Figure 2, which highlights the difference in risk of unplanned readmission for white and Black patients. In addition, for procedures where Black patients were not at an increased risk of death, such as transcatheter aortic valve replacement and colon cancer surgery, there was still an increased likelihood for them to be readmitted to a hospital for an unscheduled reason.
Two of the procedures we rate, TAVR and AVR, are used to treat the same underlying condition, severe aortic stenosis. Untreated, aortic stenosis can lead to shortness of breath, fatigue and increased risk of heart failure. These symptoms make daily life activities, such as walking and climbing stairs challenging. Furthermore, half of all patients with untreated severe aortic stenosis die within just two years, according to new research. In order to explore racial inequities in care, we focused on these two parallel procedures, as we observed one of the largest gaps in mortality between Black and white patients undergoing AVR, a trend that was not present in TAVR. A review of the existing literature, analysis of Medicare claims and patient and physician interviews suggest that racial disparities in outcomes for valve replacement procedures stem from differential access to advanced treatment options, and high-quality, culturally-competent care.
Since its introduction into clinical care in 2011 following initial FDA approval, TAVR has proven to be a safe and effective treatment for aortic stenosis. It offers certain advantages for the patient over the standard surgical procedure, such as reduced postoperative hospital length of stay, fewer complications from major bleeding, and an increased likelihood that the patient can recover at home rather than needing the additional medical support of a skilled nursing home or rehab unit.
These patient advantages are also favorable for the healthcare industry as they reduce the overall financial and care delivery burden on hospitals. Given these advantages, the rapid adoption of this new technology has not been surprising. Annual volumes of TAVR procedures in the Medicare fee-for-service population have increased almost 8-fold from a little over 5,000 in 2012 to nearly 40,000 in 2018.
But, who gets to reap the benefits of this new innovation? One study found that non-Black patients are 2.8 times more likely to receive TAVR and that each $10,000 increase in a person’s income increases their likelihood of receiving TAVR by 10%. “A majority of Black or African American patients with aortic stenosis don’t get recommended treatment,” says Dr. Antoine Keller, a cardiac surgeon at Baton Rouge General Medical Center. Our analysis of Medicare inpatient claims supports Keller’s assertion; we found that, of people with a diagnosis of aortic stenosis, white patients were more likely to have any intervention than Black patients ( Figure 3 and Figure 4). This difference was particularly marked in TAVR, where 17.5% of white patients compared to 10.4% of Black patients received the procedure over the seven year period.
Even more concerning is the fact that this gap has been widening over time, while the difference in who receives surgical AVR has remained about the same. Despite the rapid expansion in TAVR, Black patients appear to have been left behind. The gap in who gets TAVR is critical, because while studies have revealed disparities between white and Black patient outcomes in surgical AVR, they have not shown this to be the case in patients undergoing TAVR. This finding holds true in the Medicare population, where we found significant disparities in mortality and readmission within thirty days of discharge between white and Black patients undergoing AVR but not TAVR. Map 1 illustrates the difference in the risk of mortality by race for these two procedures in counties with Black Medicare-age populations of 20 percent or greater.
One potential explanation for the observed disparity in AVR but not TAVR is that hospitals offering TAVR must comply with certain regulations put into place by the Centers for Medicare & Medicaid Services. These include maintaining minimum heart surgery procedure volumes and employing at least two physicians with cardiac surgery privileges and at least one with interventional cardiology privileges. Given these requirements, hospitals offering TAVR are more than one and a half times as likely to be teaching hospitals, and have 1.7 times the annual valve replacement volume than hospitals offering exclusively AVR. Indeed, the proportion of patients with adverse outcomes, such as death, readmission, stroke, length of hospital stay and discharge to a location other than home was much more variable across AVR-only hospitals than those offering both approaches. In Map 2, we observe that the location of many of these high-volume TAVR hospitals in relation to high-density, Medicare-eligible Black populations creates potential geographical barriers. Access to high quality care, or lack thereof, is an important driver of health disparities. If all Black patients had received their care at a TAVR-approved center, an estimated 72 deaths and 263 readmissions could have been avoided from 2012 to 2018.
Part of the solution to ameliorating racial disparities will likely require deliberate actions to invest in communities of color and place health care resources closer to minority patients. Transportation can be a real barrier when the nearest TAVR facility is 50 miles away. Keller underscored the role of “TAVR deserts” in contributing to access inequities, noting that distance is not only an issue for the surgery itself, but also for follow-up care, which typically occurs four times within the first year. But barriers to access are not just physical. “Culturally competent team-based care” can also help reduce inequities, according to Dr. David Holmes, an interventional cardiologist at Mayo Clinic in Rochester, Minn. Clear communication of the risks and benefits of different treatment options can engender trust and allow the patient to make an informed decision about what is best for them. Holmes also noted the success of Novant Heart and Vascular Institute, a Charlotte-based hospital where a team of African-American physicians began a TAVR program to serve Black patients in their area. When physician demographics are more representative of the patients they treat, decision making is more participatory, which may translate to greater patient satisfaction and better outcomes.
Carrie Cobb, a resident of a rural area outside Baton Rouge, provides an example of how the health care system can function effectively for patients of the Black community. Her cardiologist had been keeping a close eye on her for a few years before referring her to Keller for surgery. He explained the benefits and risks of her treatment options, which allowed her to feel confident in her decision to pursue TAVR. She expressed a high level of trust in the physician and hospital to care for her during the procedure, which she largely attributes to the communication between her and her doctor. Her experience was very positive: “I feel great. I feel good. I feel 35 again!” The surgery has improved her quality of life. Despite the success of her experience, her story highlights some of the barriers to access that many patients face. The closest hospital to Cobb that offered TAVR was roughly 60 miles away. Thankfully, her husband was able to drive her to and from the procedure, but for many Americans, access to high-quality TAVR care is more of a challenge. In the 2020-21 U.S. News Best Hospital ratings, 18 states, home to more than 32 million residents, lacked a high performing TAVR center.
One critical piece of reducing racial disparities lies in understanding them better. While racial disparities exist in hospital care, a multitude of inequities are present long before a person arrives in the operating room. Who is screened? Who is diagnosed? Which procedure does a patient receive? What hospitals are located near them, and how good are they? For health care to become a right and not a privilege, actions will need to be taken not only within hospital walls in assuring race does not inform suggested treatment, but also in our communities more broadly as we think about expanding access to high quality health care. Though this series only scratches the surface of the racism and structural inequality that is baked into our health care system, we hope that in exposing these disparities we can begin to address them.
Clarification 08/25/20: A previous version of this article was clarified to include Dr. David Holmes’ location.