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Race And Sex-based Disparities In Treatment And Mortality Following Pulmonary Embolism Intervention
Kasthuri Nair, MS
1, Amelia Fogle, BS
1, Adriana Gutierrez Yllu, MD
2, Swathi Raikot, MBBS
3, Nkiruka Arinze, MD
4, Brent Keeling, MD
5, Yazan Duwayri, MD, MBA
4, Gerard McGorisk, MD
6, Wissam Jaber, MD
7, Olamide Alabi, MD, MS
3.
1Emory University School of Medicine, Atlanta, GA, USA,
2Rollins School of Public Health, Emory University, Atlanta, GA, USA,
3Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University School of Medicine and Atlanta VA Healthcare System, Atlanta, GA, USA,
4Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA,
5Division of Cardiothoracic Surgery, Emory University, Atlanta, GA, USA,
6Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA,
7Division of Interventional Cardiology, Emory University Hospital, Atlanta, GA, USA.
Objective.Race and sex are known risk factors for pulmonary embolism (PE); however, little is known about race and sex-based outcomes following PE intervention(s). We sought to better understand the intersectionality of race and sex in relation to the receipt of treatment modalities and mortality.
Methods. We examined adult PE hospital admissions who had subsequent PE interventions (systemic thrombolysis, catheter-based interventions, and surgical thrombectomy) between 2015-2019 at a large academic healthcare network using our institution’s administrative database. Given a low volume of patients who identified as Hispanic and/or race other than Black or White, we compared the following groups: White Men, White Women, Black Men, and Black Women. Bivariate analyses performed included Chi-square tests to compare categorical variables and Kruskal-Wallis tests for nonparametric data. Logistic regression was used to identify predictors of overall mortality.
Results. The 913 patients had a median age of 64.2[IQR:51.4,73.8] years, 51.0% (n=466) were Black, and 47.9% (n=437) were Male. Compared to White patients, Black patients were younger at the time of hospital admission and a higher proportion had advanced kidney disease and history of venous thromboembolism
(Table 1). White men received catheter-based interventions more often (and systemic thrombolysis less often) than the other groups. Overall mortality was highest for Black patients versus White patients (56.9%% vs 43.1%, p=0.032) and this finding remained while examining the intersection of race and sex: Black women (32.2%), Black men (24.6%), White men (23.0%), and White women (20.2%). Compared to catheter-based interventions, systemic thrombolysis had an increased risk of mortality (OR, 3.1; 95% CI, 1.91–5.02). Compared to White patients, Black patients had increased risk of mortality (OR, 1.38; 95% CI, 1.03-1.85, p=0.032). Among patients who underwent systemic thrombolysis, there was no statistically significant race-based difference in mortality (OR, 1.3; 95% CI, 0.97-1.75, p=0.08).
Conclusions. Disparities in receipt of specific PE interventions can lead to increased mortality. Exploring this disparity may help improve survival for patients from structurally disadvantaged communities. Next steps include semi-structured interviews with stakeholders to delineate facilitators and barriers to the receipt of catheter-based interventions.
Table 1. Demographic and Clinical Characteristics Among Patients Who Received Pulmonary Embolism Interventions, 2015-2019 | | | | | | |
| TotalN=913 | White WomenN=212 | Black WomenN=264 | White MenN=235 | Black MenN=202 | p-value |
| Age, median (IQR) | 64.5(51.8 – 74.0) | 66.5(52.8 – 76.1) | 63.7(48.9 – 73.4) | 66.7(55.6 – 76.6) | 60.4(48.9 – 70.8) | <.0001 |
| Insurance status | |
| Public | 260 (28.5%) | 71 (33.5%) | 71 (26.9%) | 62 (26.4%) | 56 (27.7%) | 0.001 |
| Private | 484 (53.0%) | 111 (52.4%) | 136 (51.5%) | 145 (61.7%) | 92 (45.5%) | |
| Medicaid | 116 (12.7%) | 21 (9.9%) | 44 (16.7%) | 15 (6.4%) | 36 (17.8%) | |
| Uninsured | 53 (5.8%) | 9 (4.2%) | 13 (4.9%) | 13 (5.5%) | 18 (8.9%) | |
| Comorbid conditions | |
| Atrial fibrillation | 65 (7.1%) | 14 (6.6%) | 21 (7.9%) | 19 (8.1%) | 11 (5.4%) | 0.671 |
| Asthma | 234 (25.6%) | 64 (30.2%) | 92 (34.8%) | 41 (17.4%) | 37 (18.3%) | <.0001 |
| Coronary artery disease | 152 (16.6%) | 30 (14.1%) | 46 (17.4%) | 34 (14.5%) | 42 (20.8%) | 0.224 |
| Chronic obstructive pulmonary disease | 181 (19.0%) | 49 (23.1%) | 62 (23.5%) | 38 (16.2%) | 27 (13.4%) | 0.012 |
| Hypertension | 366 (40.1%) | 81 (38.2%) | 124 (47.0%) | 78 (33.2%) | 83 (41.1%) | 0.017 |
| Diabetes mellitus | 24 (2.6%) | 7 (3.3%) | 9 (3.4%) | 1 (0.4%) | 7 (3.5%) | 0.111 |
| Advanced kidney disease | 144 (15.8%) | 17 (8.0%) | 52 (19.7%) | 22 (9.4%) | 53 (26.2%) | <0.001 |
| History of Venous Thromboembolism | 182 (19.9%) | 38 (17.9%) | 64 (24.2%) | 33 (14.0%) | 47 (23.3%) | 0.018 |
| IQR, interquartile range; Advanced kidney disease includes all patients with chronic kidney disease stage 3 or higher including those on hemodialysis |
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