Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA.
Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA; Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Medical Center, Iowa City, IA.
Am Heart J. 2021 Apr;234:23-30. doi: 10.1016/j.ahj.2020.12.018. Epub 2020 Dec 31.
Patterns of diffusion of TAVR in the United States (U.S.) and its relation to racial disparities in TAVR utilization remain unknown.
We identified TAVR hospitals in the continental U.S. from 2012-2017 using Medicare database and mapped them to Hospital Referral Regions (HRR). We calculated driving distance from each residential ZIP code to the nearest TAVR hospital and calculated the proportion of the U.S. population, in general and by race, that lived <100 miles driving distance from the nearest TAVR center. Using a discrete time hazard logistic regression model, we examined the association of hospital and HRR variables with the opening of a TAVR program.
The number of TAVR hospitals increased from 230 in 2012 to 540 in 2017. The proportion of the U.S. population living <100 miles from nearest TAVR hospital increased from 89.3% in 2012 to 94.5% in 2017. Geographic access improved for all racial and ethnic subgroups: Whites (84.1%-93.6%), Blacks (90.0%- 97.4%), and Hispanics (84.9%-93.7%). Within a HRR, the odds of opening a new TAVR program were higher among teaching hospitals (OR 1.48, 95% CI 1.16-1.88) and hospital bed size (OR 1.44, 95% CI 1.37-1.52). Market-level factors associated with new TAVR programs were proportion of Black (per 1%, OR 0.78, 95% CI 0.69-0.89) and Hispanic (per 1%, OR 0.82, 95% CI 0.75-0.90) residents, the proportion of hospitals within the HRR that already had a TAVR program (per 10%, OR 1.07, 95% CI 1.03-1.11), P <.01 for all.
The expansion of TAVR programs in the U.S. has been accompanied by an increase in geographic coverage for all racial subgroups. Further study is needed to determine reasons for TAVR underutilization in Blacks and Hispanics.
在美国，经导管主动脉瓣置换术（TAVR）的应用模式及其与 TAVR 利用方面种族差异的关系尚不清楚。
我们利用医疗保险数据库确定了 2012 年至 2017 年美国大陆的 TAVR 医院，并将其映射到医院转诊区（HRR）。我们计算了每个居住邮政编码到最近 TAVR 医院的行车距离，并计算了一般人群以及按种族划分的人群中，有多少人居住在距离最近的 TAVR 中心 100 英里以内。我们使用离散时间风险逻辑回归模型，研究了医院和 HRR 变量与 TAVR 项目开设之间的关联。
TAVR 医院的数量从 2012 年的 230 家增加到 2017 年的 540 家。居住在距离最近 TAVR 医院 100 英里以内的美国人口比例从 2012 年的 89.3%增加到 2017 年的 94.5%。所有种族和族裔群体的地理可达性都有所提高：白人（84.1%-93.6%）、黑人（90.0%-97.4%）和西班牙裔（84.9%-93.7%）。在 HRR 内，教学医院（OR 1.48，95%CI 1.16-1.88）和医院床位规模（OR 1.44，95%CI 1.37-1.52）开设新 TAVR 项目的可能性更高。与新 TAVR 项目相关的市场因素是黑人（每增加 1%，OR 0.78，95%CI 0.69-0.89）和西班牙裔（每增加 1%，OR 0.82，95%CI 0.75-0.90）居民的比例，HRR 内已经开展 TAVR 项目的医院比例（每增加 10%，OR 1.07，95%CI 1.03-1.11），所有 P 值均<.01。
美国 TAVR 项目的扩展伴随着所有种族亚组地理覆盖范围的扩大。需要进一步研究以确定黑人和西班牙裔人群中 TAVR 利用率低的原因。
