TEVAR Alleviates Racial Disparity for Thoracic Aneurysm Repair

African-American patients are at higher risk of death and complications after surgical thoracic aortic aneurysm repair compared with whites, largely because blacks are more likely to undergo the procedure at low-volume hospitals. On the other hand, outcomes are similar for both groups when they receive thoracic endovascular aneurysm repair (TEVAR) because blacks are not disproportionately treated at low-volume centers, according to a study published online November 22, 2012, ahead of print in the Journal of Vascular Surgery.

Philip P. Goodney, MD, MS, of Dartmouth-Hitchcock Medical Center (Lebanon, NH), and colleagues used Medicare claims data from 1999 to 2007 to examine 30-day mortality and complications in 12,573 patients who underwent open repair (4% of whom were African-American) and 2,732 patients who underwent TEVAR (8% of whom were African-American).

Compared with their white counterparts, blacks undergoing surgical repair were more likely to be treated at very-low volume hospitals with 29%  having the procedure at centers in the lowest quintile of hospital volume (< 5 procedures per year; P = 0.003). However, for TEVAR, African-American patients were more evenly distributed across hospital volume categories (P = 0.347).

No Difference in Endovascular Mortality

In the surgical cohort, African-American patients had higher 30-day mortality than white patients, while rates were similar for TEVAR (table 1).

Table 1. 30-Day Mortality

In multivariable analyses, African-American race was associated with increased perioperative mortality with open surgery (OR 2.0; 95% CI 1.5-2.5, P < 0.001) but not TEVAR (OR 0.9; 95% CI 0.6-1.5, P = 0.721). However, for patients presenting with rupture, perioperative mortality was higher with surgical repair compared with TEVAR (45% vs. 28.4%, P < 0.001) regardless of race. This effect was similar in both white (P < 0.001) and African-American patients (P < 0.02).

Overall, 5-year survival in the surgical cohort was lower for African-Americans than whites (61% vs. 71%, P < 0.001). However, in the TEVAR group there were no significant differences in 5-year survival by race (log-rank, P = 0.563).

Hospital volume was inversely related to perioperative mortality for surgical repair, ranging from a rate of 13.5% in very low volume hospitals to 7.3% in very high-volume hospitals; P < 0.001). No such relationship was seen for TEVAR.

Leveling the Playing Field

“This study shows that while new technology sometimes is unevenly applied across the [United States], in some settings it seems that new technology, specifically in the area of vascular surgery, can narrow the gap that exists in outcomes across different racial groups,” Dr. Goodney said in a telephone interview with TCTMD. “I was hopeful that we would see the results we did, but honestly somewhat surprised, as well.”

According to Dr. Goodney, the study has implications beyond race for improving the care of specific patient subgroups such as those with poor access to care or the indigent. For example, although one school of thought is to send such patients to higher-volume regional hospitals to improve their care, “instead of moving patients around, we changed the procedure [over the last decade from surgery to TEVAR] and made it a little simpler and a little safer so that we can get good results at more hospitals,” he said. “The implication here is that new technology sometimes really can level the playing field. That is a model that I believe we may be able to use more broadly in surgery to attempt to eliminate racial and other disparities.”

Dr. Goodney added that the study also is a good example of why it is important to ensure that new technology is disseminated broadly to both academic centers and community hospitals, to allow care to reach diverse and disadvantaged populations and not simply those with access to tertiary centers.

 

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Source:
Goodney PP, Brooke BS, Wallaert J, et al. Thoracic endovascular aneurysm repair, race, and volume in thoracic aneurysm repair. J Vasc Surg. 2012;Epub ahead of print.

 

 

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• Minorities Less Likely to Receive Surgery from High-Volume Providers