Comment
In this retrospective study of patients diagnosed with ATAA, we found
that patients with lower socioeconomic status had lower rates of
follow-up with a cardiovascular specialist and were less likely to
receive timely follow-up imaging. In turn, these patients suffered worse
outcomes in that they were more likely to present with symptoms at time
of aortic surgery or die before ever being followed up. To date, there
have been no studies that we know of examining the influence of SES on
thoracic aortic aneurysm surveillance.
The majority of patients in our cohort had moderate-sized aneurysms
(<5cm) without other significant risk factors (i.e. genetic
syndromes), a population in which the appropriate interval for
surveillance imaging is currently debated.16, 19, 20The 2010 ACCF/AHA Task Force guidelines recommend all patients with TAA
be managed by a cardiologist or cardiac surgeon; however, they leave the
imaging interval to the discretion of the provider.4While annual CT scan is reasonable after initial aneurysm detection or
in genetically predisposed patients with stable ATAA size, we expect
that intervals will be longer for those without associated risk factors.
For this reason, we used a conservative interval of 2 years from last CT
scan to evaluate whether patients were receiving regular surveillance
with CT or echocardiography. We observed that patients in the ADI
quartile with lowest SES were less likely to receive surveillance
imaging for ATAA aneurysm within 2 years of last CT scan, even after
adjusting for common comorbidities that warrant thoracic imaging. While
we are unable to establish a causal relationship, the observed
difference in successful referral to a cardiovascular specialist
indicates the need for improved systems for establishing longitudinal
follow-up in individuals with decreased access to care.
Several studies have linked lower patient socioeconomic status with
disparities in cardiovascular healthcare.6, 21, 22While our study lacks information about previously employed measures of
SES, such as insurance status and income level, the use of ADI in health
outcomes research is growing as it provides a more comprehensive measure
of disadvantaged status while offering greater granularity than
estimates based on zip code alone. Within cardiac surgery, a study by
Patrick et al. utilized ADI to show that lower SES is associated with
receipt of fewer arterial conduits during CABG, resulting in worse
long-term survival.10 Lower income patients with
coronary artery disease also face significant financial barriers to
accessing routine care, such as medical checkups, Hgb A1c and lipid
measurement, and antihypertensive treatment.23 This is
particularly important for patients with TAA as a higher incidence of
TAAs has been observed in more socioeconomically deprived individuals,
perhaps due to the greater prevalence of uncontrolled hypertension which
is a known risk factor for adverse outcomes in TAA.20,
24 Prior to this, the understanding of how socioeconomic barriers
impact outcomes in patients with TAA was limited to only to survival
after aortic dissection.13, 14 This catastrophic
outcome is avoidable with periodic monitoring and elective intervention.
Several previous studies have observed Black patients to experience
poorer cardiovascular healthcare and outcomes.25-27The low number of non-white patients in our sample made it difficult to
evaluate differences in care associated with race. The lack of
statistically significant association between surveillance care and race
may be due to the collinearity between ADI and race, with ADI being a
variable accounting for a larger variation in the care.
Ultimately, in our study, patients of lower SES experienced inadequate
aneurysm surveillance and follow-up and greater likelihood of presenting
for surgery with symptoms. This finding is supported by another recent
study of 51,282 patients from the Society for Thoracic Surgeons (STS)
Database, which found that both uninsured as well as Medicaid patients
were significantly more likely to undergo nonelective thoracic aortic
operation than privately insured patients (RR 1.77 [1.70-1.83] and
1.18 [1.10-1.26], respectively).12 Though our
study lacks data on cause of mortality, the worrisome observation that
92% of patients in the lowest SES quartile (Q4) presented with symptoms
is concerning for the subset of patients who may have died from aneurysm
complications before having a chance to be seen.
Healthcare institutions must be proactive in engaging marginalized
populations via interventions targeted at both patients and providers.
This may take the form of automatically generated alerts to ordering
providers when radiographic scans detect aneurysms above a certain size.
In addition, public health initiatives should expand outreach to
marginalized communities with education regarding the significant
mortality associated with TAAs and the treatable nature of the disease.