Insured Black patients are less likely to undergo minimally invasive heart valve replacement or repairs -- relatively safe procedures -- than their white counterparts, new research shows.
Black patients who need a mitral valve replacement are more likely to have operations that involve opening the chest and cutting through the breastbone to reveal the heart, a new study shows. White patients, however, are more likely to have an operation in which two small slits are cut in the chest allowing for insertion of tubes to replace or repair the faulty valve.
Because of differences in the procedures, Black patients are more likely to suffer complications and die than white patients, said researcher Dr. Laurent Glance, a professor of anesthesiology and perioperative medicine at the University of Rochester Medical Center in upstate New York.
This disparity existed even though many of the Black patients in the study were insured through Medicaid, he said. "This study suggests that just increasing access to health insurance alone is not enough to fix disparities," Glance said.
What is needed, he said, is equal access to hospitals with experienced surgeons who do lots of minimally invasive valve replacements.
For the study, the researchers used data from a nationwide database of nearly 104,000 patients who had mitral valve surgery at 1,085 hospitals between 2014 and 2019.
They found that Black patients had 35% lower odds of having minimally invasive surgery and 62% higher risk of serious complications or dying compared with white patients. Hispanic patients had 26% higher odds of major complications or death compared with white patients, but they were as likely as white patients to get minimally invasive surgery.
Researchers said some of the disparity in care may owe to most Black patients being treated at under-resourced hospitals where surgeons are less experienced and minimally invasive surgery isn't offered.
Though hospitals have not been segregated by law in decades, researchers said they remain quite segregated in practice.
Black patients had 31 times the odds of being treated at hospitals that serve a very high proportion of Black patients than at a hospital that serves only a few, Glance noted.
Black patients were also more likely to be treated by surgeons who do few mitral valve replacements. These surgeons were 20 times less likely to do minimally invasive procedures than surgeons who do many mitral valve surgeries, researchers noted.
This disparity is just one example of the differences that affect all health care, according to Glance's colleague and co-author Dr. Peter Knight, a professor of cardiac surgery at University of Rochester Medical Center.
"I think if we're honest with ourselves, that disparity exists with almost all health care but as you get more technologically sophisticated, it becomes more obvious," he said.
Heart surgery and minimally invasive surgery is typically available only in large or academic medical centers or other hospitals that have the resources to develop these programs, Knight said.
"That's a financial issue that ultimately translates into being less well dispersed in communities of color," he said.
The same is true for mitral valve repair, which is often not an option in inner-city hospitals that serve poor communities, Knight said.
"Programs in inner cities have fewer resources to be able to do high-tech stuff," he said.
The issue boils down to how to resolve these differences in health care for the rich and the poor, Knight said.
"We have to ask ourselves, as a society, whether we're OK with this two-tiered or multi-tiered health care system where people with wealth and means have a different kind of health care than poor people," he said.
An expert who reviewed the findings said he believes newer, safer procedures should be available to all patients regardless of race or economic status.
"Minimally invasive mitral valve surgery may offer a number of advantages compared to the conventional open chest surgical approach," said Dr. Gregg Fonarow, director of the Ahmanson-UCLA Cardiomyopathy Center and co-chief of the UCLA Division of Cardiology in Los Angeles. These include a lower risk of surgical site complications, faster recovery, and high patient satisfaction.
The findings in this study have important implications for identifying and reducing disparities in quality care for patients with heart valve disease, Fonarow said.
"Equitable access to experienced cardiothoracic surgeons and high-quality medical centers should be a priority for patients with valvular heart disease," he said.
The study was published online Dec. 21 in JAMA Network Open.
For more on mitral valve surgery, visit the American Heart Association.
SOURCES: Laurent Glance, MD, professor, anesthesiology and perioperative medicine, University of Rochester Medical Center, Rochester, N.Y.; Peter Knight, MD, professor, cardiac surgery, University of Rochester Medical Center, Rochester, N.Y.; Gregg Fonarow, MD, director, Ahmanson-UCLA Cardiomyopathy Center, and co-chief, UCLA Division of Cardiology, Los Angeles; JAMA Network Open, online, Dec. 21, 2022