Several racial and socioeconomic inequities continue to drive disparities in care and outcomes among patients with pulmonary embolism (PE) in the U.S., according to a study presented at the 64th ASH Annual Meeting and Exposition. Mary Cushman, MD, of the University of Vermont, said the findings should provide health care workers with motivation to examine different ways to deliver PE care, particularly in communities of color or economically deprived regions.
“Clinicians might examine their own care delivery to see if there is differential use of certain treatments in their hospital based on insurance status (a proxy for poverty) or racial group,” Dr. Cushman added, “or if there are differences in mortality by these factors.”
The study included an analysis of all hospitalizations of adults with a discharge diagnosis of acute PE from the Nationwide Inpatient Sample (2016-2018). Researchers identified 1,124,204 hospitalizations related to PE, including 615,570 with a primary diagnosis of PE. A subgroup of 66,570 patients with high-risk PE was defined by codes for cardiac arrest, cardiopulmonary resuscitation, shock, vasopressor use, or ventilator support.
The researchers used multivariable logistic regression to evaluate associations of race and ethnicity, primary payer type, and income with the use of advanced PE therapy and in-hospital death. “Advanced PE therapy” was defined as catheter-directed treatment, extracorporeal membrane oxygenation, surgical embolectomy, or thrombolysis.
Across the sample, the rate of PE hospitalization was 14.9 per 10,000 person-years. The PE hospitalization rate increased across race and ethnicity groups, starting with 3.0 in patients of Asian descent, 5.6 in Native American patients, 6.0 in Hispanic patients, 13.1 in white patients, and 20.1 in Black patients.
Overall, 5.5% of all patients received advanced PE therapy, while 19% of patients with high-risk PE received advanced treatment. In an adjusted analysis, Black patients were 13% less likely than white patients to receive advanced therapy. Asian, Native American, and Hispanic patients were 24%, 19%, and 8%, respectively, less likely to receive advanced treatment compared with white patients.
Additionally, patients with Medicare, Medicaid, or “other-insured” (which includes uninsured individuals) were 27%, 32%, and 14%, respectively, less likely than patients with private insurance to receive advanced therapy. The researchers noted that this pattern was similar in patients with high-risk PE.
The in-hospital case-fatality rate for all patients was 6.4%, and half of patients with high-risk PE died. Compared with white patients, the mortality rates were 10% greater for Hispanic patients and 50% greater for Asian patients. Patients in the lowest income quartile had a 9% greater mortality.
In the high-risk PE subgroup, patients who were Black, Hispanic, or Asian had between 11% and 50% greater mortality than white patients. Greater mortality was also observed in “other-insured” patients compared with patients with private insurance.
Although the study identified considerable disparities in PE management and care, the researchers noted that the reasons for these social inequities remain unanswered.
Dr. Cushman said that the study findings shine “[a] spotlight on the problem so that further research can aim to understand the reasons” behind these inequities. “Many of these things are rooted in structural racism and policies like redlining,” she commented.
Regarding future research, Dr. Cushman noted that investigators can examine the quality of hospitals across different geographic regions, unconscious biases among health care workers, and health-seeking behaviors among people of color.
Any conflicts of interest declared by the authors can be found in the original abstract.
Farmakis I, Cushman M, Valerio L, et al. Social determinants of health and pulmonary embolism treatment and mortality: The nationwide inpatient sample. Abstract #140. Presented at the 2022 American Society of Hematology Annual Meeting and Exposition; December 10, 2022; New Orleans, Louisiana.