Black and Hispanic Patients Not Accessing High-Volume TEER Centers

A new study is highlighting racial/ethnic disparities in access to treatments for severe mitral regurgitation (MR), with investigators reporting that Black and Hispanic patients are less likely than white patients to undergo transcatheter edge-to-edge repair (TEER) at high-volume centers.

The study is in line with others highlighting gaps in care across racial/ethnic lines for various cardiovascular treatments.

“It’s a disparity we’ve seen in other forms of therapy, whether it’s in terms of surgery, like CABG or surgical aortic valve replacement, as well as with minimally invasive procedures like PCI and TAVR,” said investigator Diala Steitieh, MD (Weill Cornell Medical College/NewYork-Presbyterian Hospital, NY). “The reason it’s important, obviously, is that you want to be able do the procedure for patients who can’t undergo surgical [mitral valve replacement] because we know it does minimize readmissions for heart failure and so on. If you have severe MR, this is something they should be offered,”  

While surgical mitral valve replacement is the standard of care for patients with severe MR, TEER is an alternative for patients at prohibitive or high surgical risk. In the COAPT trial, for example, which included patients with moderate-to-severe or severe functional MR deemed to be poor candidates for surgery, use of TEER reduced heart failure hospitalizations and mortality when compared with medical therapy alone. In EVEREST II, which included primary MR patients eligible for mitral valve replacement or repair surgery, TEER was less effective than surgery at reducing MR but was associated with better safety and similar clinical outcomes.

To TCTMD, Steitieh pointed out that high-volume centers have been shown to have better clinical outcomes, including fewer complications, and lower rates of hospital readmissions with advanced structural heart interventions. High-volume operators are also more likely to have a greater likelihood of procedural success.

“Since high-volume centers have better outcomes, we wanted to know not only if [Black/Hispanic patients] were accessing TEER, but also if they were accessing high-volume centers,” she said.

Higher Mortality Among Hispanics

For the study, which was published July 13, 2022, in JSCAI, researchers analyzed 2016 data from eight states in the Healthcare Cost and Utilization Project’s Statewide Inpatient Databases. In the analysis, a high-volume center was defined as a hospital that performed 25 or more TEERs per year, a cutoff that has been associated with lower rates of surgical bailout, fewer readmissions for cardiovascular causes, and shorter hospital stays, according to investigators.

In total, 1,567 patients (47% female) were included in the analysis, of whom 72% underwent TEER at a high-volume center.

In terms of patient characteristics, there was no significant difference in age, sex, frequency of hypertension, diabetes, dyslipidemia, and obesity between the low- and high-volume cohorts, although patients with congestive heart failure (CHF) and chronic kidney disease (CKD) were more commonly treated at high-volume hospitals. The vast majority of patients treated with TEER were white (88.8%), with Black and Hispanic patients making up just 5.9% and 5.3% of those treated. Minority patients were more likely to have comorbidities, such as diabetes, CKD, obesity, CHF (Black patients only), and prior MI (Hispanic patients only).  

In multivariate analysis, Black and Hispanic patients were 59% and 51% less likely to be treated with TEER at a high-volume center, respectively, when compared with white patients (P < 0.001 for both). Moreover, Hispanic patients had a threefold higher risk of in-hospital mortality compared with white patients (adjusted OR 3.32; 95% CI 1.15-9.63). There was no difference in mortality between Black and white TEER-treated patients. Because of the limitations of the database, researchers were unable to assess more granular endpoints, such as readmissions for HF.

Given that Black and Hispanic patients tended to be sicker, Steitieh said there’d be an expectation they should receive care at a high-volume center. Yet that wasn’t the case. “They were undergoing TEER at a much lower rate at these high-volume centers,” she said.

Finally, investigators noted the proportion of white to minority patients undergoing TEER in several US zip codes and these zip codes correlated with the location of high-volume centers. There was no significant interaction between socioeconomic status and race.

Referral Biases and Other Reasons

Disparities in access to TEER may be related to differences in socioeconomic factors, including lower rates of preventive healthcare in minority groups that result in fewer referrals for TEER, said Steitieh. A lack of accessible structural heart centers in some neighborhoods or an unwillingness to undergo invasive or surgical procedures may explain some—but not all—of the discrepancies.

“There must be some form of referral bias, or something of that nature, only because when you look at the actual zip codes of patients, minority patients tend to be in denser, more populated areas, and those areas tend to have bigger hospitals that do high-volume procedures,” she said. “There’s no obvious answer as to why we’re observing this. We do know that [minorities] are generally sicker, they’re coming in nonelective, and there is just something about their outpatient care that is probably lacking. Whether that means a referral to a lower-volume center—that’s a connection that isn’t quite clear.”

Wayne Batchelor, MD (Inova Heart and Vascular Institute, Falls Church, VA), who wasn’t involved in the study, had another theory, noting that the demographics of patients treated at different sites tend to track closely with the investigational device exemption (IDE) studies. 

“These [IDE] sites are often academic institutions who often don’t care for the same types of patients as other urban and rural community hospitals,” he said. “Since the research sites have a ‘head start’ with respect to launching their commercial programs, the patients who are treated through the commercialization process tend to follow the ones who were included in the research trials.”

As to why racial/ethnic minority groups aren’t getting the same type of care as white patients, Batchelor said the reasons are complex and interconnected. “There are impediments in multiple areas, including patient factors, healthcare system factors, and disease-related factors, such as the prevalence of disease within various groups,” he observed. “There are [also] diagnostic, referral and treatment biases along the way.”

In 2019, Batchelor, along with other members of the American College of Cardiology’s Interventional Section Leadership Council, published a perspective highlighting racial/ethnic disparities in terms of access to transcatheter and surgical aortic valve replacement for aortic stenosis. To counteract the imbalance, they proposed a four-part intervention intended to narrow the treatment gap, including implementing quality-improvement programs, effective culturally competent communication and team-based care, improved patient healthcare access, education, and effective diagnosis, and changing the research paradigm.    

“Unfortunately, we’re seeing a consistent trend across multiple structural heart procedures where patients who are in need of these procedures aren’t getting them for a multitude of reasons,” said Batchelor.