The Impact of Gender, Ethnicity, and Social Deprivation on Access to Surgical or Transcatheter Aortic Valve Replacement in Aortic Stenosis: A Retrospective Database Study in England
By Dr. Caoimhe Rice
Reducing health inequalities is a major public health focus, across many diseases from cancer diagnoses, heart procedures, access to mental health services, to vaccine uptake. In our study, published in the BMJ journal, Open Heart, on October 4, in collaboration with NHS colleagues and sponsored by Medtronic Limited, we focused on differences in access to aortic heart valve replacement by surgical or percutaneous transcatheter (keyhole) techniques among individuals with aortic valve stenosis.
Aortic stenosis is a heart valve disease prevalent in 1.5 people per 1000 people aged over 55 years [1] and affects people more as age increases [2]. Almost two thirds of people are thought to be symptomatic and in need of aortic valve replacement, either surgical or transcatheter [1]. A recent paper [3] reported that there were 78 transcatheter aortic valve interventions (TAVI) procedures per million people in the UK, lower than the European average of 141 per million people.
In our study, we found that people with aortic stenosis of female gender, black or south Asian ethnicity, and higher deprivation had a lower chance of receiving an aortic valve replacement. Furthermore, our research highlighted that ‘timeliness’ of aortic valve replacement differed by ethnicity and deprivation. A ‘timely’ procedure was one that was planned, i.e., not an urgent or emergency procedure, and that occurred before ‘cardiac decompensation’ such as heart failure. A lower proportion of people with black or south Asian ethnicity or higher deprivation had a timely procedure.
"Our findings highlight the importance of initiatives such as the Women’s Health Strategy for England, which commits to detecting and tackling systemic issues to close the gender health gap. Similar initiatives to address ethnic and socioeconomic health gaps are needed."
Public health initiatives may be required to increase clinician and public awareness of unconscious bias, even down to the level of the technology used. Blair et al. [4] proposed that unconscious bias in the healthcare system and among healthcare professionals such as a 'male as default' approach, may contribute to biases in healthcare provision for women. The independent NHS Race and Health Observatory highlighted issues with pulse oximeters, which were developed and calibrated on lighter skin, during the COVID-19 pandemic [5]. Forthcoming research, public health initiatives and policy should include intersectional analyses looking at the combined impact of gender, ethnicity, and deprivation on individuals.
Our study used anonymised real-world linked datasets collated from NHS GP clinical management systems (the Clinical Practice Research Datalink [CPRD] Aurum) and NHS hospital (the Hospital Episode Statistics [HES]) reimbursement data. The use of such datasets in research allows the examination of healthcare differences among the general population and can contribute to tackling health inequities. In particular, it could allow investigation of differences in healthcare when gender, ethnicity and deprivation intersect for instance, establishing the impact for women of minority ethnicities who live in the most deprived areas.
Find out more about our efforts in supporting health equity, here.
REFERENCES
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Strange GA, Stewart S, Curzen N, et al. Uncovering the treatable burden of severe aortic stenosis in the UK. Open Heart 2022; 9:e001783. Available at: https://openheart.bmj.com/content/9/1/e001783. Accessed 15 February 2022.
- Nkomo VT, Gardin JM, Skelton TN, Gottdiener JS, Scott CG, Enriquez-Sarano M. Burden of valvular heart diseases: a population-based study. The Lancet 2006; 368:1005–1011.
- Ali N, Faour A, Rawlins J, et al. ‘Valve for Life’: tackling the deficit in transcatheter treatment of heart valve disease in the UK. Open Heart 2021; 8. Available at: https://pubmed.ncbi.nlm.nih.gov/33767000/. Accessed 29 June 2022.
- Blair I V, Steiner JF, Havranek EP. Unconscious (Implicit) Bias and Health Disparities: Where Do We Go from Here? Background: What We Know So Far. The Permanente Journal/ Spring 2011; 15. Available at: https://implicit.harvard.edu. Accessed 15 August 2023.
- Dada O. Pulse oximetry and racial bias: Recommendations for national healthcare, regulatory and research bodies. London: 2021
Supporting health equity
At CorEvitas, we are committed to working hand in hand with our partners to generate high-quality, fit-for-purpose real-world evidence (RWE) that not only recognizes and accounts for health inequities in development and assessment, but also quantifies its impact on healthcare outcomes. Together, we can create a more equitable healthcare system that ensures access to essential care and a deeper understanding of the many factors associated with the costs of disease for all individuals, regardless of their background or circumstances.