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Canadian Journal of Cardiology

Relationship of Neighbourhood Social Deprivation and Ethnicity on Access to Transcatheter and Surgical Aortic Valve Replacement: A Population-Level Study

Published:October 10, 2022DOI:https://doi.org/10.1016/j.cjca.2022.10.002

      Abstract

      Background

      Wide geographic variation in access to transcatheter (TAVR) and surgical (SAVR) aortic valve replacement exists, but the impact of socioethnic factors on the geographic variation of AS management in Ontario, Canada, is unknown.

      Methods

      Neighbourhood rates of AS admissions, as a proxy for AS burden, and downstream TAVR and SAVR referrals and procedures were estimated for the 76 subregions in Ontario. To determine if the socioethnic geographic variations in referrals and procedures were concordant or discordant with AS burden, we calculated Pearson correlation coefficients to determine the relationship between AS burden and each of TAVR referrals, TAVR procedures, SAVR referrals, or SAVR procedures. We developed generalised linear models to determine the association between social deprivation indices captured in the Ontario Marginalization index and the rates of AS burden as well as TAVR/SAVR referral and procedures.

      Results

      There was wide geographic variation that was concordant between AS burden and the referral and procedure rates for TAVR and SAVR (correlation coefficients 0.86-0.96). Increased dependency was associated with higher rates of both TAVR/SAVR referrals and procedures (rate ratios 1.63-2.22). Neighbourhoods with a higher concentration of ethnic minorities were associated with lower AS burden as well as lower rates of both SAVR and TAVR referrals and procedures (rate ratios 0.57-0.85).

      Conclusions

      An important ethnic gradient exists in AS burden and in both referral and completion of TAVR and SAVR in Ontario. Further research is necessary to understand if this gradient is appropriate or requires mitigation.

      Résumé

      Contexte

      Il existe de grandes disparités géographiques dans l’accès aux interventions de remplacement valvulaire aortique par cathéter (RVAC) et de chirurgie de remplacement valvulaire aortique (CRVA). On ignore toutefois le poids des facteurs socioethniques dans les disparités géographiques de la prise en charge de la sténose aortique (SA) en Ontario (Canada).

      Méthodologie

      Le taux d’hospitalisations pour une SA par secteur géographique (utilisé pour estimer le fardeau de la SA) ainsi que les orientations pour un RVAC ou une CRVA et les interventions elles-mêmes ont été estimés pour les 76 sous-régions de l’Ontario. Afin d’établir si les disparités géographiques socioethniques des orientations et des interventions étaient en phase avec le fardeau de la SA, nous avons calculé les coefficients de corrélation de Pearson pour déterminer le lien entre le fardeau de la SA et chacun des éléments suivants : les orientations pour un RVAC, les interventions de RVAC, les orientations pour une CRVA et les interventions de CRVA. Des modèles de régression linéaire généralisés ont été utilisés pour déterminer le lien entre les mesures de défavorisation socioéconomique issues de l’indice de marginalisation ontarien et le fardeau de la SA, d’une part, et les orientations et interventions de RVAC et de CRVA, d’autre part.

      Résultats

      Les disparités géographiques observées concordaient avec le fardeau de la SA et les taux d’orientation pour un RVAC ou une CRVA et les taux d’interventions (coefficients de corrélation : 0,86 à 0,96). Un indice plus élevé de dépendance économique était associé à des taux plus élevés d’orientation pour un RVAC ou une CRVA et d’interventions (rapports de taux de 1,63 à 2,22). Les secteurs géographiques à plus forte concentration de minorités ethniques étaient associés à un fardeau de SA plus faible et à des taux plus faibles d’orientations pour un RVAC ou une CRVA et d’interventions (rapports de taux de 0,57 à 0,85).

      Conclusions

      Il existe en Ontario un gradient ethnique important dans le fardeau de la SA et dans les orientations et les interventions de RVAC et de CRVA. D’autres recherches s’imposent pour mieux comprendre si ce gradient est approprié ou si une mitigation est nécessaire.

      Graphical abstract

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      Linked Article

      • Dissecting Aortic Stenosis Disparities in Ontario, Canada: Do Gaps Persist in the Transcatheter Era?
        Canadian Journal of Cardiology
        • Preview
          The growing awareness of and willingness to manage aortic valve disease has resulted in an increase in aortic valve procedures. In recent years, transcatheter aortic valve replacement (TAVR) has increasingly and sequentially been adopted in high-risk, intermediate-risk, and even low-risk surgical patients requiring aortic valve replacement. Although surgical aortic valve replacement (SAVR) remains the procedure of choice in lower-risk patients, TAVR has been used with optimal outcomes in these patients,1 with potential economic benefits over time as a result of shorter intensive care unit and hospital lengths of stay and improved early recovery.
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