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Inadequate Surveillance of Valvular Disease May Help Explain Disparities in Outcomes

Key findings

  • Increased age correlated with a significantly lower likelihood of receiving appropriate surveillance
  • Black, female and older patients and patients on Medicaid were significantly less likely than white, male and Medicare patients, respectively, to receive appropriate transthoracic echocardiographic surveillance of valvular disease
  • Interventions are needed to improve adherence to consensus guidelines for surveillance of chronic valvular lesions, particularly for these types of patients

As in many other disease states, there are substantial disparities in clinical outcomes among patients with valvular heart disease. For example, it is known that black patients with aortic stenosis are less likely than white patients to receive aortic valve replacements, and women have greater mortality following valve surgery.

To correct these disparities, as well as to uncover vulnerabilities in care delivery that can benefit all patients, understanding why these disparities exist is critical. In that context, Varsha K. Tanguturi, MD, cardiologist and instructor at Harvard Medical School, and Jason H. Wasfy, MD, MPhil, medical director, Massachusetts General Hospital Physicians Organization, and colleagues investigated the relationship between sociodemographic factors and receipt of transthoracic echocardiograms (TTEs). Guidelines recommend regular TTE surveillance of chronic valvular lesions to prevent delayed repair and poor cardiovascular outcomes.

Black patients, female patients, older patients and Medicaid patients are less likely to receive appropriate TTE surveillance of valvular disease, the researchers found by reviewing Mass General data. They report their findings in a research letter published in JACC Cardiovascular Imaging.

The research team reviewed records of 42,289 adults who underwent inpatient or outpatient TTEs between January 2001 and March 2016 for surveillance of primary aortic stenosis, aortic insufficiency and/or mitral regurgitation. The analysis included 130,725 TTEs. The primary outcome was whether a patient received a TTE within the guideline-recommended timeframe for the disease type and severity.

The average patient age was 64, and 51% of the study population was male. Most patients studied (85%) were white, with 4% self-identified as non-Hispanic black and 3% as Hispanic; 56% had Medicare, 38% had commercial insurance and 5% had Medicaid. The researchers found the following statistically significant differences:

  • Women were 10% less likely than men to receive appropriate TTE surveillance
  • Black patients were 26% less likely than white patients to be monitored appropriately
  • Medicaid patients were 15% less likely than those on Medicare to be monitored appropriately
  • Private insurance had similarly appropriate surveillance to Medicare patients

Increased age correlated with a significantly lower likelihood of receiving appropriate surveillance TTEs for each decade of life after 60 years.

A sensitivity analysis, conducted using a separate cohort of patients receiving most of their care at Mass General, confirmed the main findings.

The researchers conclude that their results should encourage interventions to improve adherence to consensus guidelines. They also call for further investigation into the clinical consequences of delayed surveillance.

This work was funded through a grant from the National Institutes of Health and Harvard Catalyst.

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