The expansion of transcatheter aortic valve implantation (TAVI) in the USA has predominantly centred on wealthier, metropolitan areas, with hospitals in poorer, more rural communities less likely to offer the procedure.
This is according to research published this week online in the journal Circulation: Cardiovascular Quality and Outcomes. Study author Ashwin Nathan (Hospital of the University of Pennsylvania, Philadelphia, USA) write that the pattern of growth of TAVI in US hospitals “has led to inequities in the dispersion of TAVI, with lower rates in poorer communities”.
Data from the Society of Thoracic Surgeons (STS)/American College of Cardiology (ACC) TVT Registry, published in the Journal of the American College of Cardiology and The Annals of Thoracic Surgery in November 2020 chart the growth of TAVI in the USA since the approval of the first TAVI device in 2011. The data show that, as of August 2020, there were 715 US TAVI sites, with TAVI programmes established in all of the 50 US states.
To chart the characteristics of hospitals that developed TAVI programmes, as well as the socioeconomic status of the patients these hospitals served, Nathan and colleagues identified fee-for-service Medicare beneficiaries aged 66 years or older who underwent TAVI between 1 January 2012 and 31 December 2018, and hospitals that developed TAVI programmes—defined as those performing 10 or more TAVI procedures over the study period.
The study team used linear regression models to compare socioeconomic characteristics of patients treated at hospitals that did and did not establish TAVI programmes and described the association between core-based statistical area level markers of socioeconomic status and TAVI rates.
The authors found that, between 2012 and 2018, 583 hospitals developed new TAVRI programmes, including 572 (98.1%) in metropolitan areas, and 293 (50.3%) in metropolitan areas with pre-existing TAVI programmes.
Compared with hospitals that did not start TAVI programs, hospitals that did start TAVI programmes treated fewer patients with dual eligibility for Medicaid (difference of -2.83% [95% confidence interval [CI], -3.78% to -1.89%], p≤0.01), higher median household incomes (difference US$2,447 [95% CI, US$1348–US$3547], p=0.03), and from areas with lower distressed communities index scores (difference -4.02 units [95% CI, -5.43 to -2.61], p≤0.01).
After adjusting for the age, clinical comorbidities, race and ethnicity and socioeconomic status, the study’s authors found that areas with TAVI programmes had higher rates of TAVI and TAVI rates per 100,000 Medicare beneficiaries were higher in core-based statistical areas with fewer dual eligible patients, higher median income, and lower distressed communities index scores.
“During the initial growth phase of TAVI programmes in the USA, hospitals serving wealthier patients were more likely to start programmes,” Nathan et al write. “This pattern of growth has led to inequities in the dispersion of TAVI, with lower rates in poorer communities,” the authors conclude.