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'Striking' Inequalities in Provision of Heart Valve Surgery

Public health initiatives are needed to understand and tackle "striking" inequalities in provision of aortic valve replacement (AVR) in England, with women, Black and Asian people, and those living in areas of deprivation much less likely to receive the procedure, according to a multi-centre research team.

The study was carried out by researchers from the Liverpool Heart and Chest Hospital, South Tees Hospitals, Guy's and St Thomas' Hospital in London, University Hospital Southampton, and Leeds Teaching Hospitals.

Their investigation found that women were 30% less likely to undergo AVR than men; Black and South Asian ethnicities had 26% and 22%, respectively, lower odds of AVR than White people, and people from the most deprived areas were 24% less likely to undergo the procedure than those in the least deprived. 

When these ethnic and deprived groups did receive an AVR, they were less likely to have had a timely procedure, performed electively before cardiac decompensation set in, the results showed.

The researchers explained that not much was known about the inclusivity of AVR provision for adults with aortic stenosis (AS) across the NHS in England, so they set out to assess gender, ethnicity, and deprivation-based differences. Data was extracted on 183,591 adults with AS recorded in English hospital episode statistics between April 2016 and March 2019, allowing researchers to identify 31,436 (17%) who subsequently had an AVR. 

They used multivariable logistic regression to estimate the odds ratio (OR) for AVR in different groups, adjusted for age, region and comorbidity. They then assessed a separate cohort of 10,069 adults with AVR in the Clinical Practice Research Datalink (CPRD) to evaluate the timeliness of their procedure, judged according to whether or not it was performed electively during a scheduled admission, and without evidence of prior cardiac decompensation. Intervention was regarded as delayed if performed during an unscheduled or urgent admission, or once there was evidence of heart failure. 

Gender, Ethnicity, and Deprivation Level Affected Odds of Having AVR

The study, published in the journal Open Heart , found striking differences based on gender, ethnicity, and deprivation level:

  • Women were less likely to receive AVR than men (OR 0.65; 95% CI 0.63 to 0.66), though there was no difference in the timeliness of the procedures undertaken
  • People of Black heritage had lower odds of AVR than White people (OR 0.70; 95% CI 0.60 to 0.82). In only 55% had the procedure been timely, compared with 65% for White people
  • Those from South Asian ethnicities were less likely than White people to have had AVR (OR 0.75; 95% CI 0.69 to 0.82) and less likely to have had timely surgery (also 55% vs 65%)
  • Those from the most deprived areas were less likely to undergo the procedure than those in the least deprived areas (OR 0.8; 95% CI 0.75 to 0.86), and timely surgery had occurred in 58% versus 77%, respectively

According to the team, their findings aligned with those of other research showing a higher prevalence of undiagnosed valvular heart disease  among people in more deprived socioeconomic groups. They noted that their study did not consider the burden of undiagnosed AS, which would "potentially amplify any disparities". They also noted that as an observational study, the results could not establish cause, nor was it designed to identify barriers to access or provision of care.

Aortic Stenosis Carries High Mortality Without Intervention

In England, AS is the valve disease most often requiring surgery, and between one-fifth and one-quarter of people with severe or very severe AS will die within 5 years without intervention, the researchers said. AVR relieves symptoms, improves quality of life, and increases life expectancy. The procedure - either transcatheter or surgical (TAVI or SAVR) – is recommended by the National Institute for Health and Care Excellence for all those with severe symptomatic AS, as well as other specific indications, they said.

Delayed operation may mean that progressive left ventricular (LV) dysfunction does not recover fully after intervention, and long waits for AVR often lead to clinical deterioration and acute hospital admission, sometimes with fatal results. It is therefore "imperative" to monitor those with asymptomatic AS carefully, and refer them for early intervention with even minor symptoms or early LV dysfunction, the researchers said. 

Further research and public health initiatives to understand and address inequalities in the timely provision of AVR in England and to identify whether disparity is related to structural or systemic inequities, genetic inequalities, or differences in patient behaviours or preferences, "should be prioritised", the team concluded.

"Public health initiatives may be required to increase clinician and public awareness of unconscious biases towards minority and vulnerable populations, to ensure timely AVR for everyone," they added.

Cardiovascular Disease a "Major Driver of Health Inequalities"

Asked to comment by Medscape News UK, Dr Sonya Babu-Narayan, consultant cardiologist and associate medical director at the British Heart Foundation, said: "Cardiovascular disease is a major driver of health inequalities and this study is further evidence of how such disparities can disproportionately affect women, people from ethnic minority backgrounds, and those living in the most socially deprived areas in England."

She said that while differences like these had been seen for some years, further research and evidence-based policies were needed "to tackle perceived and actual barriers to fair access to diagnosis and timely treatment of aortic stenosis, a condition which can put lives at risk."

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