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Hindawi Journal of Interventional Cardiology Volume 2021, Article ID 8837644, 8 pages https://doi.org/10.1155/2021/8837644 Research Article Distressed Communities Index in Patients Undergoing Transcatheter Aortic Valve Implantation in an Affluent County in New York 1 1 2 2 Thomas Bilfinger , Allison Nemesure, Robert Pyo, Jonathan Weinstein, 2 2 2 2 1 Giridhar Korlipara, Daniel Montellese, Shamim Khan, Neal Patel, Henry Tannous, 2 2 2 2 Ting-Yu Wang, Ely Gracia, Susan Callahan, and Puja B. Parikh Division of Cardiothoracic Surgery, Department of Medicine, State University of New York at Stony Brook, Stony Brook, NY, USA Division of Cardiovascular Medicine, Department of Medicine, State University of New York at Stony Brook, Stony Brook, NY, USA Correspondence should be addressed to omas Bilfinger; thomas.bilfinger@stonybrookmedicine.edu Received 13 August 2020; Revised 7 July 2021; Accepted 13 August 2021; Published 24 August 2021 Academic Editor: ach N. Nguyen Copyright © 2021 omas Bilfinger et al. is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background. e clinical impact of the distressed communities index (DCI), a composite measure of economic well-being based on the U.S. zip code, is becoming increasingly recognized. Ranging from 0 (prosperous) to 100 (distressed), DCI’s association with cardiovascular outcomes remains unknown. We aimed to study the association of the DCI with presentation and outcomes in adults with severe symptomatic aortic stenosis (AS) undergoing transcatheter aortic valve intervention (TAVR) in an affluent county in New York. Methods. e study population included 286 patients with severe symptomatic AS or degeneration of a bioprosthetic valve who underwent TAVR with a newer generation transcatheter heart valve (THV) from December 2015 to June 2018 at an academic tertiary medical center. DCI for each patient was derived from their primary residence zip code. Patients were classified into DCI deciles and then categorized into 4 groups. e primary and secondary outcomes of interest were 30-day, 1- year, and 3-year mortality, respectively. Results. Among 286 patients studied, 26%, 28%, 28%, and 18% were categorized into DCI groups 1–4, respectively (DCI <10: n � 73; DCI 10–20: n � 81; DCI 20–30: n � 80; DCI >30: n � 52). Patients in group 4 were younger with worse kidney function compared to patients in groups 1 and 2. ey also had smaller aortic annuli and were more likely to receive a smaller THV. No significant difference in hospital length of stay or distribution of in-hospital, 30-day, 1-year, and 3-year mortality was demonstrated. Conclusions. While the DCI was associated with differences in the clinical and anatomic profile, it was not associated with differences in clinical outcomes in this prospective observational study of adults undergoing TAVR suggesting that access to care is the likely discriminator. U.S. zip code, is becoming increasingly recognized. Ranging 1. Introduction from 0 (prosperous) to 100 (distressed), DCI’s association e success of new technology can be measured by the time with cardiovascular outcomes remains unknown [2]. it takes to penetrate a given market. With high research and Transcatheter aortic valve intervention (TAVR), which was development costs, adaptation of new technology is typically introduced over a decade ago, has radically changed how we occurring along socioeconomic gradients [1]. e clinical treat severe symptomatic aortic stenosis (AS) and bio- impact of the distressed communities index (DCI), a prosthetic aortic valve degeneration [3]. While data are composite measure of economic well-being based on the emerging that TAVR programs are concentrated in 2 Journal of Interventional Cardiology outcomes (e.g., all-cause mortality, disabling stroke, new wealthier areas, raising questions about access, no data exist on the association between the DCI and outcomes following pacemaker, and hospital readmission), as well as 1- and 3- year all-cause mortality, were also collected. is study was TAVR. Accordingly, we aimed to study the association of the DCI with presentation, management, and outcomes in approved by our Institutional Review Board. A waiver of adults with severe symptomatic AS or bioprosthetic valve consent to use data prospectively was obtained for all degeneration undergoing TAVR at an academic tertiary care patients. center in an affluent county in New York. Continuous variables were presented as mean- s± standard deviation (SD) and compared using one-way ANOVA. Categorical variables were presented as percent- 2. Methods ages and compared with the chi-squared test. Histogram of We prospectively included all patients undergoing TAVR at the DCI was performed for the Suffolk County population, our overall study population, and for patients requiring Stony Brook University Hospital, an academic tertiary medical center, in our institutional registry. Adults (age>18 pacemaker, hospital readmission, and/or discharge to a skilled nursing facility. SPSS version 23.0 (SPSS Inc., Chi- years) with severe symptomatic AS and/or failure of a bioprosthetic valve and undergoing TAVR from December cago, IL) was used for data analysis, and a two-tailed P value 2015 to June 2018 were included in this study. of 0.05 was regarded as statistically significant. Suffolk County is the easternmost county on Long Is- land, New York. It comprises 107 zip codes, each of which 3. Results comprises at least 500 inhabitants [4]. e DCI is available for all zip codes with more than 500 residents, which e distribution of DCI scores on Long Island, New York, is captures 99% of the U.S. population. It is a composite score skewed towards a low DCI score (Figure 1). Our study based on 7 metrics: no high-school degree, housing vacancy population included 286 consecutive patients who under- rate, adults not working, poverty rate, median income ratio, went TAVR from December 2015 to June 2018 at a single change in employment, and change in business establish- academic tertiary care institution. Among the 286 patients ments [2]. e 7 evenly weighted variables are used to studied, 26%, 28%, 28%, and 18% were categorized into DCI calculate a zip code rank compared with its geographic peers groups 1–4, respectively (DCI <10: n � 73; DCI 10–20: and then normalized to obtain a raw distress score that n � 81; DCI 20–30: n � 80; DCI >30: n � 52). Patients in ranges from 0 (no distress) to 100 (severe distress). e 7 group 4 had increased serum creatinine compared to pa- socioeconomic status (SES) indicators were obtained from tients in groups 1 and 2 (Table 1). ey also had smaller 5-year estimates from the 2014 American Community aortic annuli and were more likely to receive a smaller THV Survey and the Census Bureau County and ZIP Code (Tables 2 and 3). No difference in age and STS predicted risk Business Pattern. e Economic Innovation Group provides of mortality was noted across the 4 groups. With respect to a heat map of DCI scores across the U.S. e number of outcomes, no significant difference in hospital length of stay valves estimated in patients with home zip codes in Suffolk or rate of in-hospital and 30-day mortality, stroke, new was obtained from Medicare claims data for all 107 Suffolk pacemaker, and readmission was detected (Table 4). e County zip codes. distribution of patients requiring a skilled nursing facility, Patients were classified into deciles of the DCI based on new pacemaker, or 30-day readmission followed the DCI the zip code of their primary address. For analysis, we histogram of that of the overall TAVR population implanted grouped DCI values> 30 together as there were few patients (Figures 2(a)–2(d)). One-year all-cause mortality rates were in each decile above 30. Demographic and medical history also similar among the groups (Figure 3), and at 3 years, 76/ extracted included age, sex, body mass index (BMI), prior 286 (26.6%) had died. coronary artery bypass graft surgery (CABG), prior aortic valve replacement (AVR), prior balloon aortic valvuloplasty 4. Discussion (BAV), prior mitral valve surgery, prior myocardial in- farction (MI), atrial fibrillation (AF), prior pacemaker/de- In this contemporary prospective study of adults undergoing fibrillator, prior stroke/transient ischemic attack, chronic TAVR at an academic medical center in an affluent county in obstructive pulmonary disease (COPD), obstructive sleep New York, several findings are noteworthy. First, patients apnea, diabetes mellitus, carotid disease, peripheral arterial with worse DCI were younger, had worse kidney function, disease, and serum creatinine (mg/dl). e Society of and were more likely to receive a smaller THV. Second, DCI oracic Surgeons (STS) predicted the risk of mortality was was not associated with early in-hospital or 30-day out- obtained for each patient. Echocardiographic data extracted comes. Finally, 1- and 3-year mortality was similar across the included aortic valve area (AVA) and index (AVAI) and left DCI groups. To our knowledge, this is the first study to assess ventricular ejection fraction (LVEF). Aortic annular area the association between the DCI and outcomes in patients and perimeter were also obtained from gated computed undergoing TAVR, during a time period where TAVR tomography angiography (CTA). Procedural data (e.g., surpassed SAVR in New York state (Table 5). A likely ex- access, anesthesia, transcatheter valve size and type, pre- planation for the absence of postprocedural differences is the dilatation, and postdilatation) and discharge data (e.g., intense competition of regional TAVR programs which all discharge antiplatelets, discharge anticoagulants, discharge perform in or near the top on the composite metric for location, length of stay (LOS), and in-hospital and 30-day benchmarking recently published [5]. Journal of Interventional Cardiology 3 Histogram of Overall Long Island Population [1.5, 11.1] (11.1, 20.7] (20.7, 30.3] (30.3, 39.9] (39.9, 49.5] (49.5, 59.1] (59.1, 68.7] (68.7, 78.3] (78.3, 87.9] Distress Index Figure 1: Histogram of the distressed communities index across Long Island, New York. Table 1: Baseline medical history. Distress index <10 Distress index 10–20 Distress index 20–30 Distress index >30 (n � 73) (n � 81) (n � 80) (n � 52) Age (years) 80± 9 81± 8 79± 8 77± 10 Female gender 36 (49.3%) 35 (43.2%) 35 (43.8%) 32 (61.5%) Weight (kg) 83± 19 80± 19 82± 21 77± 18 Height (meters) 1.67± 0.11 1.68± 0.10 1.66± 0.11 1.63± 0.11 Body mass index (kg/m ) 29.5± 5.8 28.0± 6.6 29.3± 6.4 27.6± 8.3 STS predicted risk of mortality (PROM) 6.4± 5.7 6.4± 4.5 6.7± 4.2 6.1± 5.4 Serum creatinine (mg/dl) 1.1± 0.5 1.3± 1.0 1.2± 0.6 1.6± 1.6 Prior coronary artery bypass grafting 18 (24.7%) 18 (22.2%) 16 (20.0%) 4 (7.7%) Prior myocardial infarction 8 (11.0%) 23 (28.4%) 23 (28.7%) 12 (23.1%) Prior aortic value replacement 1 (1.4%) 2 (2.5%) 7 (8.8%) 3 (5.8%) Prior balloon aortic valvuloplasty 1 (1.4%) 4 (5.0%) 1 (1.3%) 3 (5.8%) Prior mitral valve surgery 3 (4.1%) 0 (0%) 7 (8.8%) 0 (0%) Prior pacemaker/defibrillator 12 (16.4%) 7 (8.6%) 13 (16.3%) 4 (7.7%) Atrial fibrillator 33 (45.2%) 33 (40.7%) 28 (35.0%) 12 (23.1%) Chronic obstructive pulmonary disease 12 (16.4%) 20 (24.7%) 19 (23.8%) 10 (19.2%) Obstructive sleep apnea 6 (8.2%) 9 (11.1%) 8 (10.0%) 2 (3.8%) Prior stroke/transient ischemic attack 11 (15.1%) 17 (21.0%) 12 (15.0%) 5 (9.6%) Carotid disease 16 (21.9%) 20 (24.7%) 21 (26.3%) 11 (21.2%) Peripheral arterial disease 4 (5.5%) 7 (8.6%) 6 (7.5%) 7 (13.5%) Diabetes mellitus 25 (34.2%) 34 (42.0%) 33 (41.8%) 20 (38.5%) Table 2: Clinical testing. Distress index <10 Distress index 10–20 Distress index 20–30 Distress index >30 P value (n � 73) (n � 81) (n � 80) (n � 52) Echocardiogram Aortic valve area (cm ) 0.71± 0.17 0.71± 0.20 0.77± 0.21 0.76± 0.19 0.146 2 2 Aortic valve area index (cm /m ) 0.38± 0.10 0.38± 0.11 0.45± 0.39 0.43± 0.12 0.134 Left ventricular ejection fraction (%) 56± 17 54± 14 54± 15 58± 15 0.623 Gated computed tomography Aortic annulus area (mm ) 447± 75 468± 95 440± 101 408± 109 0.010 Aortic annulus perimeter (mm) 77± 10 79± 9 77± 9 73± 11 0.018 e association between socioeconomic status and aortic aneurysm (AAA) [9], as well as worse morbidity and/ health outcomes, particularly with cardiovascular disease, or mortality in the setting of aortic aneurysm [10], aortic has been well documented [6]. Low SES has been linked with dissection [11], stable coronary artery disease [12], and acute a higher prevalence of multiple cardiovascular conditions, coronary syndromes [13, 14]. Low SES has also been as- including AS [7], rheumatic heart disease [8], and abdominal sociated with delayed and/or absent referral for cardiac Frequency 4 Journal of Interventional Cardiology Table 3: Procedural information. Distress index <10 Distress index 10–20 Distress index 20–30 Distress index >30 (n � 73) (n � 81) (n � 80) (n � 52) Conscious sedation 64 (87.7%) 61 (75.3%) 61 (77.2%) 37 (71.2%) Transfemoral access 73 (100.0%) 81 (100.0%) 79 (98.8%) 52 (100.0%) Predilatation 61 (83.6%) 65 (80.2%) 52 (65.0%) 35 (67.3%) Transcatheter value type Edwards SAPIEN 3 58 (79.5%) 65 (80.2%) 59 (73.8%) 42 (80.8%) Medtronic Evolut R/PRO 15 (20.5%) 16 (19.8%) 21 (26.3%) 10 (19.2%) Transcatheter valve size 20 mm 5 (6.8%) 2 (2.5%) 2 (2.5%) 6 (11.5%) 23 mm 20 (27.4%) 23 (28.4%) 25 (31.3%) 21 (4.4%) 26 mm 33 (45.2%) 30 (37.0%) 31 (38.8%) 20 (38.5%) 29 mm 14 (19.2%) 25 (30.9%) 19 (23.8%) 2 (3.8%) 34 mm 1 (1.4%) 1 (1.2%) 3 (3.8%) 3 (5.8%) Postdilatation 3 (4.1%) 4 (4.9%) 5 (6.3%) 1 (1.9%) Table 4: Discharge information. Distress index <10 Distress index 10–20 Distress index 20–30 Distress index >30 P value (n � 73) (n � 81) (n � 80) (n � 52) Discharge prescriptions Aspirin 70 (95.9%) 71 (89.9%) 76 (96.2%) 49 (96.1%) 0.254 Clopidogrel 44 (60.3%) 49 (62.0%) 49 (62.0%) 35 (68.6%) 0.806 Ticagrelor 0 (0%) 2 (2.5%) 1 (1.3%) 4 (7.8%) 0.038 Warfarin 16 (21.9%) 21 (26.6%) 14 (17.7%) 10 (19.6%) 0.576 Apixaban 6 (8.2%) 5 (6.3%) 9 (11.4%) 1 (2.0%) 0.239 Rivaroxaban 2 (2.7%) 1 (1.3%) 2 (2.5%) 1 (2.0%) 0.923 Dabigatran 3 (4.1%) 1 (1.3%) 3 (3.8%) 0 (0%) 0.370 Discharge location 0.545 Home 58 (79.5%) 63 (79.7%) 69 (87.3%) 42 (82.4%) Skilled nursing facility 15 (20.5%) 16 (20.3%) 10 (12.7%) 9 (17.6%) Length of stay (days) Admission to discharge 5.1± 5.3 5.7± 6.6 5.7± 5.1 6.2± 6.7 0.776 TAVR procedure to discharge 3.1± 2.1 8.0± 41.1 3.2± 2.6 3.3± 4.0 0.424 In-hospital Major adverse cardiac events 4 (5.5%) 10 (12.3%) 7 (8.8%) 3 (5.8%) 0.402 All-cause mortality 0 (0%) 2 (2.5%) 1 (1.3%) 1 (1.9%) 0.609 Disabling stroke 2 (2.7%) 1 (1.2%) 0 (0%) 0 (0%) 0.329 New pacemaker 2 (3.3%) 8 (10.8%) 6 (9.0%) 2 (4.2%) 0.282 30-day (includes in-hospital outcomes) Major adverse cardiac events 4 (5.5%) 14 (17.3%) 10 (12.5%) 4 (7.7%) 0.102 All-cause mortality 0 (0%) 2 (2.5%) 1 (1.3%) 2 (3.8%) 0.397 Disabling stroke 2 (2.8%) 2 (2.5%) 1 (1.3%) 0 (0%) 0.643 New pacemaker 2 (3.3%) 11 (15.5%) 8 (12.1%) 2 (4.3%) 0.055 All-cause readmission 11 (15.3%) 21 (26.9%) 21 (26.6%) 10 (20.0%) 0.267 procedures [15, 16] as well as poor outcomes following penetration of the new technology [31]. Nathan A. et al. multiple cardiovascular interventions including PCI recently presented data, however, which suggest that TAVR [17–19], CABG [20–22], aortic and/or mitral valve surgery programs may be concentrated in wealthier areas raising [21, 23–25], infrainguinal bypass [26, 27], and aortic an- questions about access (Nathan A. et al. Stable Ischemic eurysm repair [28–30]. Heart Disease and TAVR. Presented at the Society for Few studies have examined the association of SES with Cardiovascular Angiography and Interventions Scientific referral for TAVR referral and/or outcomes [31, 32]. One Session; April 28–May 1, 2021 (virtual meeting)). study examining data from the New York State Department DCI has been associated with higher rates of postop- Statewide Planning and Research Cooperative System erative morbidity and mortality following CABG [33, 34]. demonstrated that the proportion of TAVR procedures One study demonstrated that, for every 25-point increase in performed in patients from low-income areas increased over the DCI, the risk-adjusted mortality following CABG in- time while that in high-income areas decreased over time, creased 14% [34]. While our study did not demonstrate any suggesting a resolution of health disparities over time due to association between the DCI and outcomes in patients Journal of Interventional Cardiology 5 Patients Discharged to SNF Overall TAVR Population 12.5 10.0 7.5 5.0 2.5 0 0.0 .00 10.00 20.00 30.00 40.00 50.00 60.00 .00 10.00 20.00 30.00 40.00 50.00 60.00 DistressIndex DistressIndex Mean = 19.41 Mean = 18.27 Std. Dev. = 10.585 Std. Dev. = 11.036 N = 286 N = 50 (a) (b) Patients with 30-Day Readmission Patients with 30-Day New Pacemaker .00 10.00 20.00 30.00 40.00 50.00 .00 10.00 20.00 30.00 40.00 50.00 DistressIndex DistressIndex Mean = 19.05 Mean = 19.95 Std. Dev. = 7.665 Std. Dev. = 8.944 N = 23 N = 63 (c) (d) Figure 2: Histogram of the distressed communities index of our study population for TAVR patients (a) overall, (b) requiring a skilled nursing facility, (c) requiring a new pacemaker, and (d) presenting with 30-day readmission. undergoing TAVR, there was a higher rate of high-risk most affluent versus the least affluent areas of the region. features in the highest DCI group, including worse renal Fourth, ethnic and racial data were not captured in this study function and smaller aortic annuli. [35–38]. e uneven distribution with which TAVR reaches Our study had a number of limitations. First, observa- certain racial and ethnic groups has been widely acknowl- tional data in this study were not centrally adjudicated but edged [38, 39]. Finally, there may be unknown confounding rather internally validated. Second, our study comprised variables contributing to the associations reported in this patients undergoing TAVR, and so, patients who were not study, and the numbers are small so that a type II error referred for TAVR were not captured. ird, the distribution cannot be completely excluded. of the DCI in Suffolk County is not generalizable to other When innovative technologies (i.e., TAVR) penetrate a regions as Suffolk County, along with its neighboring county specific population, the relationship between socioeconomic of Nassau, is among the most affluent areas in the state of disparities and health outcomes can be variable. is pro- New York. As a result, we are unable to compare differences spective observational study of adults with severe symp- tomatic AS or bioprosthetic aortic valve degeneration in truly distressed (i.e., DCI >80) versus prosperous (i.e., DCI <20) areas, and so, we were only able to compare the suggests that once detected and referred for TAVR, Frequency Frequency Frequency Frequency 6 Journal of Interventional Cardiology 20 p = 0.877 18.5 16.3 15.4 13.7 Distress Index < 10 Distress Index 10-20 Distress Index 20-30 Distress Index > 30 Figure 3: Rates of 1-year all-cause mortality categorized by the distressed communities index group. Table 5: TAVR/SAVR in New York state. SAVR TAVR Year Total SAVR total Elective Urgent/emergent TAVR total Elective Urgent/emergent 2015 5990 3856 (64.4%) 2553 (66.2%) 1303 (33.8%) 2134 (35.6%) 1455 (68.2%) 679 (31.8%) 2016 7094 3746 (67.6%) 2531 (67.6%) 1215 (32.4%) 3348 (47.2%) 2451 (73.2%) 897 (26.8%) 2017 7074 3101 (43.8%) 2156 (69.5%) 945 (30.6%) 3973 (56.2%) 2988 (75.2%) 985 (24.8%) 2018 6911 2841 (41.1%) 1912 (67.3%) 929 (32.7%) 4070 (58.9%) 3166 (77.8%) 904 (22.2%) differences in outcomes across the DCI remain similar [5] N. D. Desai, S. M. O’Brien, D. J. Cohen et al., “Composite metric for benchmarking site performance in transcatheter rendering access and case selection, the likely discriminators. aortic valve replacement,” Circulation, vol. 144, no. 3, pp. 186–194, 2021. Data Availability [6] D. A. Alter, C. D. Naylor, P. Austin, and J. V. 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Journal of Interventional Cardiology – Hindawi Publishing Corporation
Published: Aug 24, 2021
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