Ensuring the Quality of Aortic Stenosis Care Relative to Race
A discussion with Dr. Jordan Strom, MD, MSc
This article is a recap of a conversation with Dr. Jordan Strom, MD, MSc that highlights recent studies, reviews and publications on the multiple contributors to disparities in aortic stenosis care, and potential ways to overcome them.
Despite greater attention to the problem and efforts to address it in recent years, racial and ethnic disparities in care continue to plague all areas of medicine, and the realm of aortic stenosis (AS) is no different. In general, individuals from underrepresented racial and ethnic groups — particularly those identifying as Black — have been shown to receive substandard care from diagnosis to treatment, with studies showing either similar or worse clinical outcomes compared to those identifying as White, as highlighted in a recent review in JACC: Cardiovascular Interventions.1
Speaking with Edwards Lifesciences, Dr. Jordan Strom, MD, MSc from Harvard Medical School and Beth Israel Deaconess Medical Center in Boston, MA, explained that there are many factors potentially playing a role in this, and healthcare professionals can take steps in their day-to-day practice to help overcome some of these management gaps while contributing to larger-scale efforts focused on the long-term goal of equitable treatment.
Where Are the Gaps?
The review in JACC: Cardiovascular Interventions summarizes research around the racial and ethnic disparities impacting the diagnosis and management of severe aortic valve stenosis. The takeaway? Underrepresented racial and ethnic groups are less likely to be diagnosed with AS despite having higher rates of many traditional risk factors for the disease; are less likely to be treated with surgical or transcatheter aortic valve replacement (SAVR or TAVR); have more complications when they are treated; and may have worse clinical outcomes.1
Dr. Strom noted that, as TAVR has been rolled out, new programs have been concentrated in areas with greater wealth and higher socioeconomic status, with individuals living in areas with lower socioeconomic status being less likely to be treated with either SAVR or TAVR. But even after accounting for location, age, sex, and clinical factors, non-White individuals, particularly those who are Black or Hispanic, have lower treatment rates.
Dr. Strom said there are likely multiple reasons behind these disparities. One possibility is related to biases during initial diagnosis. A study in the Journal of the American Heart Association,2 for instance, delved into the racial and ethnic differences in the clinical diagnosis of AS, showing that non-Hispanic Black and Asian individuals were less likely than non-Hispanic Whites to receive a diagnosis of AS after transthoracic echocardiography.2
There could also be issues around referral patterns, care delivery, and social determinants of health impacting aspects of patients' lives, like the ability to miss work to attend medical appointments, the availability of transportation to access medical care, language barriers, a lack of trust of the healthcare system among minority communities, and other structural barriers to accessing advanced care for AS, according to Dr. Strom.
Dr. Strom was involved in a study published in JACC: Advances3 that indicates that racial segregation, as one aspect of structural racism, could explain at least some of the gaps in care. He and his colleagues showed that, among Medicare beneficiaries who were Black, those living in counties with high versus low racial segregation were less likely to receive an AS diagnosis and undergo TAVR. However, the same phenomenon wasn't observed for White patients, who were overall more likely to receive an AS diagnosis with no difference in the likelihood of treatment if they lived in an area with high racial segregation.3
The authors of the JACC: Cardiovascular Interventions review state that the reasons for the observed disparities are a complex interplay of socioeconomic, cultural, and patient- and provider-centric factors. Factors that likely play a role in differences in receipt of TAVR procedures include patients' mistrust of physicians and the entire health system, patients' denial or misunderstanding of the grave risks associated with untreated AS, and the lack of access to care and qualified services.1
What Surgeons, Interventional Cardiologists, and Others Can Do
Whatever the reason, it's clear from the literature cited in the review that AS is not managed equitably across the population1, and as explained by Dr. Strom, there are both long- and short-term solutions that can start to hopefully narrow — and eventually close — those gaps.
Equity needs to be promoted across all levels, from individual clinicians up to the hospitals and healthcare systems. One suggestion is to redouble efforts to recruit people from racial and ethnic minority groups to pursue healthcare careers. "We want healthcare professionals who look like our patients and who can connect to our patients and overcome these barriers and issues of trust that have been longstanding within the healthcare community," Dr. Strom said.
Next, unconscious biases can be tackled when clinicians take steps to objectively analyze and address the disparities in their own practices. “Nobody thinks they're delivering biased care,” said Dr. Strom, but when looking at his own center's data, accounting for demographics, clinical factors, and study indications it revealed there were some disparities in receipt of echocardiography, which spurred additional efforts on the part of the medical center to focus on ensuring diversity, equity, and inclusion. "We have to unmask these unconscious biases by showing to people that it happens at their doorstep," Dr. Strom said.
But there are also solutions that can be potentially implemented over a shorter timeframe. Making the diagnosis of AS and referral for treatment more datadriven and regimented — rather than based on an individual physician's "clinical gestalt" — could help overcome some of the issues that have been observed.
To address the gap between diagnosis and treatment, Dr. Strom's group and others have been working to create tools to identify patients with severe symptomatic AS and bring them to the attention of physicians. It's known, according to Dr. Strom, that there's about a three-month delay between diagnosis and treatment in patients with AS and that those delays are related to increased mortality. One study in Circulation: Cardiovascular Interventions, for instance, showed that over time, wait times for patients seeking treatment for severe AS, both SAVR and TAVR, have increased, and that has been accompanied by increasing risks of mortality and hospitalizations for heart failure.
"There's this tremendous opportunity to be able to get people into the cardiologist’s office equitably and earlier, and part of that is making the process relatively more automated," Dr. Strom said, adding that artificial intelligence (AI) software may ultimately help facilitate this type of effort. Technological solutions wouldn't be dependent on a primary care physician or cardiologist referring a patient for treatment, as the system could alert the surgeon or interventional cardiologist who would be performing the valve replacement directly. That has the potential to eliminate some of the racial and ethnic disparities stemming from biases earlier in the process.
Also, simple alerts in the electronic medical record at the point of care could trigger appropriate follow-up and consideration of referral for aortic valve replacement and would be independent of a patient's racial and ethnic background.
“The hope is that these kinds of solutions will overcome some of these disparities over the short term and contribute to the longer-term goal of improving the equitability of the healthcare system,” said Dr. Strom. He also noted, however, that these tools are just in the research stage at this point. “They still need to be validated and evaluated to ensure they don't introduce other biases before widespread rollout.”
"It's really important, before we start to use these technologies in practice, that we understand what kinds of biases may be introduced, conscious or unconscious, that ultimately contribute to downstream outcomes, because there is a tremendous promise for these types of technologies to be useful, but we have to make sure we're using them fairly and equitably across populations," explained Dr. Strom.
Time to Act
It's helpful to point out disparities where they're occurring as a first step, according to Dr. Strom, who credited professional societies, like the American College of Cardiology and the American Heart Association (AHA), for helping to highlight problems. But that's not enough.
"At the end of the day, we need more research into why those disparities exist and if there are actionable steps we can take as a society — and as a healthcare community — to improve on a local, regional, and national level," Dr. Strom said, adding that these problems in healthcare are really the consequence of larger societal issues.
To that end, the AHA launched the Target: Aortic Stenosis program in 2020, with Edwards Lifesciences as the national sponsor. The initiative has the aim to improve the quality of care and outcomes overall, and importantly, "this effort to measure quality and quantify site performance is anticipated to help address current disparities in the treatment of patients with AS based on sex, race, and ethnicity," according to a pilot study in Circulation: Cardiovascular Quality and Outcomes.5
As the country changes and evolves, the work to ensure equitable management of AS for all is ongoing.
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