Socioeconomic and Racial Disparities: a Case-Control Study of Patients Receiving Transcatheter Aortic Valve Replacement for Severe Aortic Stenosis.

Background: We sought to quantify socioeconomic disparities in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR) at an urban, tertiary referral center.

Methods: This retrospective case-control study identified 67 patients with severe AS (aortic valve [AV] area ≤1 cm or AV area index ≤0.60 cm/m or AV velocity ≥40 mmHg) who underwent TAVR from November 5, 2013 to June 10, 2014. Study subjects were matched to controls with severe AS without TAVR in a 4:1 age-frequency match. Demographic data were collected using electronic medical records. Area-based median household income was obtained by geocoding patients' addresses and linking with census data. Charlson comorbidity index for all subjects was calculated.

Results: Income disparity was significant in that with every $10,000 increase in income, the odds of receiving TAVR increased by 10% (p = 0.05). Non-blacks were significantly more likely to receive TAVR than blacks (odds ratio [OR] 2.812, confidence interval [CI] 1.007-7.853; p = 0.048). No differences in comorbidities were found between the two groups. Post hoc analysis to identify etiologies of the found disparities examined differences of AV area and AV area index, indication for two-dimensional echocardiography (echo), symptoms prior to echo, and action after echo within the control group. Black race significantly impacted the TAVR status despite the same AV area (OR 0.33, CI 0.09-0.97, p = 0.043). After echo, blacks were more likely to decline AVR, be lost to follow-up, and not be referred to cardiology (OR 4.41, CI 1.43-13.64; p = 0.010).

Conclusion: Socioeconomic and racial disparities were associated with patients with severe AS receiving TAVR at a major referral center. This study emphasizes the importance of improving access to standard of care for these subgroups of cardiac patients.