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Race and Sex-Based Disparities in Treatment and Mortality Following Pulmonary Embolism Intervention
Kasthuri Nair
1, Amelia Fogle
1, Adriana Gutierrez Yllu
2, Swathi Raikot
3, Nkiruka Arinze
4, Brent Keeling
5, Yazan Duwayri
4, Gerard McGorisk
6, Wissam Jaber
7, Olamide Alabi
3 1Emory University School of Medicine, Atlanta, GA;
2Emory University School of Public Health, Atlanta, GA;
3Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University School of Medicine and Atlanta VA Healthcare System, Atlanta, GA;
4Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University School of Medicine, Atlanta, GA;
5Division of Cardiothoracic Surgery, Emory University, Atlanta, GA;
6Division of Cardiology, Emory University School of Medicine, Atlanta, GA;
7Division of Interventional Cardiology, Emory University Hospital, Atlanta, GA
Title: Race and Sex-Based Disparities in Treatment and Mortality Following Pulmonary Embolism Intervention
Background.Race and sex are well 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 race and the intersection of race and sex as they relate to the receipt of treatment modalities and mortality.
Methods. We examined adult hospital admissions for PE 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 performed comparisons of the following groups: White Men, White Women, Black Men, and Black Women. In the bivariate analysis, Chi-square tests were performed to compare categorical variables and Kruskal-Wallis test for nonparametric data. Logistic regression was used to identify predictors of overall mortality.
Results. Among 913 patients in the cohort, the median age was 64.2[IQR:51.4,73.8] years, 51.0% (n=466) were Black, and 47.9% (n=437) were Male. Black women and Black men were younger at the time of hospital admission and had a higher proportion of patients with advanced kidney disease and previous history of venous thromboembolism compared to their White counterparts
(Table 1). White men received catheter-based interventions more often (and systemic thrombolysis less often) than Black men, Black women, and White women. 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 was associated with 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 race and sex-based receipt of catheter-based interventions over systemic thrombolysis 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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