乌鸦传媒

At the American Heart Association (AHA) virtual meeting, AHA presented its 2021 Chairman's Award to Clyde W. Yancy, MD, MSc, of Northwestern University in Chicago. An important theme at this year's meeting surrounded the racial/ethnic and socioeconomic inequities that continue to exist in healthcare access.

In a recent , researchers looked at disparities in transcatheter aortic valve replacement (TAVR) access among Medicare patients living in large metropolitan areas with TAVR programs.

In this exclusive 乌鸦传媒 video, Yancy -- who co-authored an with Ajay Kirtane, MD, that accompanied the study -- discusses how we need to be careful when adding to the list of already well-established health disparities.

Following is a transcript of his remarks:

There were a number of important themes that emerged within the American Heart Association's Scientific Sessions, but also in a contemporaneous way, with AHA's Scientific Sessions -- one of which, we engaged uniquely in our role as deputy editor with JAMA Cardiology.

Really intriguing work brought forward by Giri and colleagues from the University of Pennsylvania. They used extensive adjustment to try to reconcile whether or not evidence of a new healthcare disparity was evident in the use and uptake of TAVR -- that is transcatheter therapies for critical AS [aortic stenosis] -- was disparate or not, as a function of race and ethnicity.

I really applaud the authors, as we have editorialized on many occasions, the time has come to go beyond describing treatment effects based on race or ethnicity alone -- Black versus white, Latino/Latinx versus white versus Black -- really don't give us sufficient insight regarding what may or may not be responsible for the observed differences.

Certainly, the ongoing analysis by race and ethnicity does serve a role, because it helps us identify evidence of the kind of health inequities that we hope to eliminate as we go forward with really striking efforts to achieve greater equity. But we should be careful, adding to the list of already well-established health disparities. TAVR is uniquely ripe for this sort of argument because at the top level, the data are hard to argue. In aggregate, both Black and Latino/Latinx count for less than 10%, maybe even as low as 5%, of the patients that are receiving TAVR. That clearly does not reflect their population, but what's the right denominator? We're thinking about an older population, so there is a longevity component that factors into the equation. We're thinking about just simply making the diagnosis of aortic stenosis. Is there an issue, just with the initial attainment of the history, prompt based on the physical examination, ordering and then receiving the echocardiogram.

Think about all of the potential barriers. Think about language barriers, if your language is discordant with a patient. Do you really pick up the subtlety for symptomatic aortic stenosis. And particularly as we expand into asymptomatic groups, that will be a real challenge.

How many patients really are having a stethoscope placed on their chest? In the limited time for patient interaction, even when that part of the exam is executed: a) how many people are still adept at doing a very critical bedside examination, and b) is there sufficient time to really listen for valve heart disease, including all the provocative maneuvers that we learned decades ago.

And then finally, yes before the echocardiogram, but is there another barrier -- economic, access -- that limits us. We have to be very careful to say that here is another race-based or ethnicity-based disparity, because there are so many additional reasons to explain why the differences that are clearly there may actually line up with other explanations -- explanations which are actionable.

But to the credit of the authors, they really did the best job possible of making adjustments for SES [socioeconomic status]: education, income, employment, and zip code. And after making those adjustments, what emerged was some evidence that after full adjustment based on zip code, there appeared to be a disproportionate way in which TAVR was experienced. But that's not sufficient to say it is an evidence base.

Does it amplify the conversation? Yes. Does it give us a direction of where we need to go? Yes. But it actually raises even more questions about the clinical science.

What do we know about the natural history of aortic stenosis? Are we aware of any genetic predispositions to either protection from calcific AS, or an exaggerated experience with calcific AS. Very clearly indicating that race is non-biological and it's not a proxy for genetics, but are those persons with an African ancestry, or European ancestry, where there is a genetic proclivity in favor of or against calcific aortic stenosis. That's a much more important scientific question to pursue than just a description about skin color, of who undergoes TAVR or not.

But I think the really good part about this is that we're still in an experience where there is a lot of debate, discussion, even rancor, when the topic of race-based differences, race-based medicine, disparities, are on the table. The more we can take a really thoughtful approach, a really scholarly approach, use best methods to really understand what difference is present. And if we find a difference, what are all the potential explanations for that difference, and really begin to partition that difference in what is one part biology, what is one part sociology, and what is one part bias. I think we would be misrepresenting the truth if we didn't have a real conversation about bias involved in any decision that requires a human to make another decision about a human, that's always going to be a process that invites some subjectivity. And subjectivity by definition invites bias.

But again, appreciate carefully one part biology, one part sociology (the community, if you will), and then one part of this whole phenomenon of bias.

I think if we can begin to think about differences going forward in the future that are deconstructed, so that a true exercise and understanding the root causes is fully executed, we'll be in a better place.

Because there's been so much discussion, and because their careful analysis with editorial commentary has appeared in a high-profile medical journal, it's on everyone's mindset. I would argue that culture change is already happening, that disease-management teams that are evaluating candidates for TAVR are thinking about this discussion, or pausing when the underrepresented minorities are on the table, or checking their biases and making a decision. Are we holding this patient back from getting the TAVR for some reason that we can't justify? That's sufficient to change the process. So we'll see what happens going forward.

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