Impact of Economic Status on Utilization and Outcomes of Transcatheter Aortic Valve Implantation and Mitraclip

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Data on the impact of economic status on Transcatheter aortic valve implantation (TAVI) and MitraClip (MC) is lacking. Patients who underwent TAVI and/or MC during 2012 to 2017 were identified in the Nationwide Readmission Database and divided by zip code estimated income quartile into 4 groups (Q1 to Q4). The utilization of TAVI and/or MC was defined as the number of TAVIs and/or MCs over all admissions with an aortic and/or mitral valve disease (AVD and/or MVD) and represented per 1,000 admissions. A total of 168,853 patients underwent TAVI; 20.6% in Q1, 26.3% in Q2, 27.3% in Q3, and 25.8% in Q4, while 15,387 patients underwent MC; 22% in Q1, 26.2% in Q2, 26.3% in Q3, and 25.5% in Q4. The annual utilization of TAVIs and/or MCs increased over the study period and was generally lower with lower income. In 2012, TAVI was performed for 8.2, 8.8, 10.8, and 11.3 per 1,000 AVD admissions in Q1, Q2, Q3, and Q4, respectively. In 2017, TAVI was performed for 54.1, 65.1, 68.6, and 71 per 1,000 AVD admissions in Q1, Q2, Q3, and Q4, respectively. In 2014, MC was performed for 1.6, 2.1, 1.8, and 1.9 per 1,000 MVD admissions in Q1, Q2, Q3, and Q4, respectively. In 2017, MC was performed for 5.6, 6.5, 8, and 8 per 1,000 MVD admissions in Q1, Q2, Q3, and Q4, respectively. In-hospital mortality, stroke, and 30-day readmissions were generally comparable across groups. Lower-income patients may be underrepresented among patients undergoing TAVI and MC despite comparable outcomes. Further studies are needed to examine the etiologies behind these disparities and identify targeted strategies for its mitigation.

Section snippets

Methods

We performed a retrospective cohort study after the STROBE checklist and using the Nationwide Readmissions Database (NRD) released by the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality.9 NRD is a nationally representative database of hospital admissions in United States (US) non-federal hospitals. It includes up to 17 million discharges each year in up to 27 states, accounting for about 57% of all hospitalizations in the US, and providing discharge

Results

Our study included 168,853 patients who underwent TAVI. Of the 168,853 patients identified, 20.6% were in the Q1 income group, 26.3% in the Q2 group, 27.3% in the Q3 group, and 25.8% in the Q4 group. Most patients in all groups were on Medicare. High-income patients were less likely to have DM, hypertension, renal failure, heart failure, and obesity, but more likely to have dyslipidemia and atrial fibrillation (Table 1). The overall utilization of TAVI was 28.8, 34.3, 36.3, and 36.7 per 1,000

Discussion

The principal findings of our study are (1) AVIs including TAVI and MC are utilized less frequently in patients with low income compared with patients in the higher income groups. (2) Clinically significant outcomes including in-hospital mortality, stroke, and 30-day readmissions were generally comparable across income groups except for a slight differential impact of ES on in-hospital mortality for patients undergoing TAVI.

Although socioeconomic disparities in the utilization of traditional

Authors Contribution

Anas M. Saad and Medhat Farwati: Conceptualization, Data curation, Formal analysis, Methodology, Project administration, Writing - original draft; Vardhmaan Jain: Methodology, Writing - original draft; Keerat Rai Ahuja: Visualization, Software, Writing - review & editing; Agam Bansal: Writing - original draft; Mohamed M. Gad: Conceptualization, Validation, Methodology, Writing - review & editing; Toshiaki Isogai: Conceptualization, Methodology, Validation, Supervision, Writing - review &

Disclosures

Authors declare no conflict of interests.

Acknowledgment

This study was made possible by a generous gift from Jennifer and Robert McNeil.

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The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this study.

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Both authors contributed equally to this manuscript

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