Abstract
Background
Tricuspid transcatheter edge-to-edge repair (T-TEER) has emerged as an effective and safe option for repair of tricuspid regurgitation in select patients. Prior studies on percutaneous cardiac interventions have demonstrated racial and ethnic disparities in procedural outcomes, but specific studies investigating T-TEER outcomes on a national level are limited.
Methods
National Inpatient Sample and International Classification of Diseases, Tenth Revision codes were used to identify patients who underwent T-TEER in the United States from 2018 to 2022. The study group was stratified based on race and ethnicity. Study outcomes included inpatient complications, outcomes, and resource utilization.
Results
A total of 2815 patients underwent T-TEER, with the racial and ethnic composition as follows: White (75.8%), Black (8.5%), Hispanic (6.2%), and Other (9.4%). Black patients had the highest incidence of major (14.6% vs 7.7% and 8.6%), overall (37.5% vs 21.5% and 28.6%), and cardiovascular (18.7% vs 7.5% and 11.4%) complications compared with White and Hispanic patients, respectively. After multivariable adjustment, Black patients had higher odds for major (adjusted OR [aOR], 1.93; 95% CI, 1.27-2.95) and overall (aOR, 2.51; 95% CI, 1.84-3.43) complications. Black and Hispanic patients had higher odds of prolonged length of stay (aOR, 2.47; 95% CI, 1.83-3.34) and (aOR, 3.40; 95% CI, 2.36-4.90), respectively.
Conclusions
Racial and ethnic disparities in T-TEER outcomes are evident, with Black patients experiencing higher major and overall complications, and Black and Hispanic patients having prolonged hospitalizations. Further investigation into the specific factors and policies driving these disparities is crucial in striving for more equitable cardiovascular care among different racial and ethnic populations.
Keywords: complications, ethnicity, outcomes, race, tricuspid transcatheter edge-to-edge repair
Introduction
Moderate to severe tricuspid regurgitation (TR) has been associated with worsening morbidity and mortality, representing a significant public health burden.1,2 For decades, tricuspid valve repair and replacement have been essential for managing severe TR, especially in symptomatic or refractory cases.3 Recently, tricuspid transcatheter edge-to-edge repair (T-TEER) has emerged as a promising alternative for high-risk surgical candidates. It has proven to be a safe intervention for severe TR and is associated with favorable outcomes, including improvements in TR reduction, symptoms, and quality of life.4, 5, 6 Consequently, the US Food and Drug Administration approval of the TriClip Transcatheter Tricuspid Valve Repair system (TriClip G4 System; Abbott) in April 2024 marks a pivotal milestone in the treatment approach for these patients.7
Disparities in background characteristics and clinical outcomes related to race and ethnicity have been observed in transcatheter valve repair, with minority groups, particularly Black and Hispanic patients, having limited access to percutaneous repair.8 Outlining the demographic characteristics and clinical outcomes based on race and ethnicity is crucial for improving health care equity. Therefore, we aimed to describe the baseline characteristics of patients who underwent T-TEER in the United States and investigate hospital outcomes based on race and ethnicity at a national level.
Methodology
Data source
We utilized data from the National Inpatient Sample (NIS) between 2018 and 2022 for patients who underwent T-TEER. The NIS is an extensive inpatient database in the United States, containing records of over 7 million hospital admissions nationwide each year from a wide array of US hospitals.9 The Agency for Healthcare Research and Quality sponsors the NIS as part of the Healthcare Cost and Utilization Project, and the database contains comprehensive data on inpatient utilization, access, cost, quality, and clinical outcomes.9 The data from the NIS is de-identified and publicly available; therefore, informed consent and institutional review board approval were not required.
Study population
We identified patients who underwent T-TEER between 2018 and 2022 using the International Classification of Diseases, 10th Revision, Clinical Modification code 02UJ3JZ (Figure 1). All patients younger than 18 years old and those with missing demographic information, including race and ethnicity, were excluded from the analysis. Race and ethnicity categories were defined as non-Hispanic White, non-Hispanic Black, Hispanic, and Other (composite of non-Hispanic Asian-American and Pacific Islander, non-Hispanic Native American, and non-Hispanic other race or multiple races). The final cohort comprised 2815 patients.
Figure 1.
Study population. Flowchart depicting the identification of the study cohort. ICD-10, International Classification of Diseases, Tenth Revision.
Outcome definition and measures
Baseline characteristics, procedural complications, and inpatient outcomes, including mortality (reported as a distinct categorical variable), length of stay (LOS), and cost of hospitalization, were compared among patients who underwent T-TEER procedures, stratified by race and ethnicity. Further, we analyzed overall complications, major complications (defined as a composite of cardiovascular, vascular, hematological, and neurological complications), cardiovascular complications (defined as a composite of pericardial effusion of any etiology requiring intervention, cardiac arrest, cardiogenic shock, ST- or non-ST-elevation myocardial infarction, and heart block), vascular complications (defined as a composite of pseudoaneurysm, access site hematoma, retroperitoneal bleeding, and venous thromboembolism), pulmonary complications (defined as a composite of acute respiratory failure, pneumothorax, and prolonged invasive ventilation), hematological complications (defined as a composite of any intraprocedural bleeding, gastrointestinal bleeding, and bleeding requiring transfusions), neurological complications (defined as a composite of cerebrovascular event and transient ischemic attack), inpatient mortality, prolonged hospital stay (defined as LOS greater than the median LOS of >2 days), and increased hospitalization cost (defined as hospitalization cost >median cost of $46,771). To estimate hospitalization costs, cost-to-charge ratios based on reimbursement from the Centers for Medicare and Medicaid Services, as provided by the Healthcare Cost and Utilization Project, were applied to the total hospital charges.9
Statistical analysis
Descriptive statistics are presented as frequencies with percentages for categorical variables and as median with IQR for continuous variables. Baseline characteristics were compared using the Pearson χ2 and Fisher exact tests for categorical variables and the Kruskal-Wallis H test for continuous variables. For crude comparison of procedural complications and in-hospital outcomes among the study groups, the Pearson χ2 test was used. To assess the independent association of race and ethnicity with outcomes of mortality, complications, LOS, and hospitalization costs, a single-step multivariable logistic regression model was used. Age (years), sex, income, insurance status, and selected Elixhauser comorbidities (deficiency anemia, cerebrovascular disorders, congestive heart failure, chronic pulmonary disease, coronary artery disease, diabetes, hypertension, liver disease) were used for adjusted analysis. All these covariates were identified based on prior literature, bivariate analysis, and the authors’ best clinical judgment. A P value of < .05 was considered statistically significant. All statistical analyses were performed using SPSS version 26 (IBM Corp) and R version 3.6 (R Core Team).
Results
Baseline characteristics
A total of 2815 patients underwent T-TEER, with the racial composition as follows: White (75.8%), Black (8.5%), Hispanic (6.2%), and other (9.4%). Significant differences were observed across multiple demographic and clinical variables (Table 1). White patients were the oldest (mean: 80 years), while Black (mean: 72 years) and Hispanic (mean: 73 years) patients were significantly younger. The proportion of female patients undergoing T-TEER was similar across all groups, ranging from 61.8% to 69.0% (P = .39). The prevalence of comorbidities varied by race. Black patients had significantly higher rates of hypertension (94.1%), anemia (50%), diabetes (41.2%), obesity (20.6%), peripheral vascular disorders (17.6%), pulmonary hypertension (58.8%), and renal failure (88.2%). Hispanic patients experienced the highest rates of chronic pulmonary disease (31.8%) and coagulopathy (31.8%), while atrial fibrillation (85.4%) was most prevalent among White patients.
Table 1.
Baseline characteristics for patients undergoing T-TEER, stratified by race and ethnicity.
| Variable | White (n = 2135, 75.8%) | Black (n = 240, 8.5%) | Hispanic (n = 175, 6.2%) | Other (n = 265, 9.4%) | P |
|---|---|---|---|---|---|
| Age, y | 80 (74-85) | 72 (65-79) | 73 (62-84) | 82 (77-85) | <.01 |
| Women | 930 (61.8%) | 105 (61.8%) | 70 (63.6%) | 100 (69.0%) | .39 |
| Comorbid conditions | |||||
| Anemia | 420 (27.9%) | 85 (50.0%) | 30 (27.3%) | 55 (37.9%) | <.01 |
| Atrial fibrillation | 1285 (85.4%) | 110 (64.7%) | 85 (77.3%) | 105 (72.4%) | <.01 |
| Congestive heart failure | 1415 (94.0%) | 160 (94.1%) | 90 (81.8%) | 140 (96.6%) | <.01 |
| Chronic pulmonary disease | 360 (23.9%) | 35 (20.6%) | 35 (31.8%) | 5 (3.4%) | <.01 |
| Coagulopathy | 155 (10.3%) | 30 (17.6%) | 35 (31.8%) | 25 (17.2%) | <.01 |
| Cardiovascular disease | 55 (3.7%) | 15 (8.8%) | NRa | NR | <.01 |
| Diabetes | 300 (19.9%) | 70 (41.2%) | 30 (27.3%) | 45 (31.0%) | <.01 |
| Weight loss | 135 (9.0%) | 25 (14.7%) | NR | 15 (10.3%) | <.01 |
| Hypertension | 1310 (87.0%) | 160 (94.1%) | 95 (86.4%) | 135 (93.1%) | .01 |
| Hypothyroidism | 440 (29.2%) | 15 (8.8%) | 20 (18.2%) | 30 (20.7%) | <.01 |
| Liver disease | 140 (9.3%) | 20 (11.8%) | 20 (18.2%) | 15 (10.3%) | .02 |
| Obesity | 130 (8.6%) | 35 (20.6%) | NR | 15 (10.3%) | < .01 |
| Peripheral vascular disorders | 125 (8.3%) | 30 (17.6%) | NR | 20 (13.8%) | < .01 |
| Pulmonary hypertension | 605 (40.2%) | 100 (58.8%) | 45 (40.9%) | 80 (55.2%) | <.01 |
| Renal failure | 700 (46.5%) | 150 (88.2%) | 35 (31.8%) | 80 (55.2%) | <.01 |
| Coronary artery disease | 740 (49.2%) | 80 (47.1%) | 40 (36.4%) | 100 (69.0%) | <.01 |
| Hospital location | |||||
| Rural | NR | NR | NR | NR | <.01 |
| Urban nonteaching | 80 (5.3%) | 15 (8.8%) | 20 (18.2%) | NR | |
| Urban teaching | 1425 (94.7%) | 155 (91.2%) | 90 (81.8%) | 135 (93.1%) | |
| Bed size of the hospital | |||||
| Small | 75 (5.0%) | NR | 15 (13.6%) | NR | <01 |
| Medium | 230 (15.3%) | 15 (8.8%) | NR | NR | |
| Large | 1200 (79.7%) | 155 (91.2%) | 85 (77.3%) | 140 (96.6%) | |
| Census division | |||||
| Northeast | 250 (16.6%) | 25 (14.7%) | NR | 40 (27.6%) | <.01 |
| Midwest | 285 (18.9%) | 40 (23.5%) | NR | NR | |
| South | 370 (24.6%) | 65 (38.2%) | 55 (50.0%) | NR | |
| West | 600 (39.9%) | 40 (23.5%) | 45 (40.9%) | 85 (58.6%) | |
| Payee | |||||
| Medicare | 1290 (85.7%) | 135 (79.4%) | 70 (63.6%) | 125 (86.2%) | |
| Medicaid | 15 (1.0%) | NR | NR | NR | <.01 |
| Private insurance | 160 (10.6%) | 25 (14.7%) | 30 (27.3%) | NR | |
| Self-pay or other | 40 (2.6%) | NR | NR | NR | |
| Median income percentile | |||||
| 1-25 | 235 (16.0%) | 80 (47.1%) | 35 (33.3%) | NR | <.01 |
| 25-50 | 320 (21.8%) | 35 (20.6%) | 30 (28.6%) | 25 (17.2%) | |
| 50-75 | 405 (27.6%) | 45 (26.5%) | 25 (23.8%) | 25 (17.2%) | |
| 75-100 | 510 (34.7%) | NR | 15 (14.3%) | 90 (62.1%) | |
Values are mean (range) or n (%).
NR, not reported; T-TEER, tricuspid transcatheter edge-to-edge repair.
Data for n < 10 are not reported as per Healthcare Cost and Utilization Project recommendations.
Insurance coverage varied significantly across racial groups, with Medicare being the most common payer among White (85.7%) and other (86.2%) patients, while Black (79.4%) and Hispanic (63.6%) patients had lower Medicare utilization (P < .01). Socioeconomic disparities were evident, with 47.1% of Black patients having the lowest median income (1st-25th percentile) compared with 34.7% of White patients in the highest income bracket (75th-100th percentile). All T-TEER procedures across racial and ethnic groups occurred in urban hospitals.
In-hospital complications
The rates of complications after T-TEER were significantly different across racial or ethnic groups (Table 2). Black patients had the highest incidence of major complications (14.6%) compared with White (7.7%) and Hispanic (8.6%) patients (P < .001). Cardiovascular complications were also most frequent in Black patients (18.7%) relative to White (7.5%) and Hispanic (11.4%) patients (P < .001). Bleeding and hematological complications were more prevalent in Black patients (14.6%) than in White (7.0%) and Hispanic (8.6%) patients (P < .001). Pulmonary complications were more prevalent in Hispanic patients (14.3%) than in White (11.5%) and Black (12.5%) patients (P < .001). Acute kidney injury was significantly higher in Black (33.3%) and Hispanic (25.7%) patients than in White patients (16.6%) (P < .001). The adjusted multivariable logistic regression model revealed that Black patients exhibit significantly higher odds of major complications (adjusted odds ratio [aOR], 1.93; 95% CI, 1.27-2.95) and overall or any complications (aOR, 2.51; 95% CI, 1.84-3.43) (Figure 2).
Table 2.
Complications in patients undergoing T-TEER, stratified by race or ethnicity.
| Variable | White (n = 2135, 75.8%) | Black (n = 240, 8.5%) | Hispanics (n = 175, 6.2%) | Other (n= 265, 9.4%) | P |
|---|---|---|---|---|---|
| Major complications | 165 (7.7%) | 35 (14.6%) | 15 (8.6%) | 15 (5.7%) | <.001 |
| Overall complications | 460 (21.5%) | 90 (37.5%) | 50 (28.6%) | 35 (13.2%) | .001 |
| Any cardiovascular event or complication | 160 (7.5%) | 45 (18.7%) | 20 (11.4%) | 25 (9.4%) | <.001 |
| Pericardial effusion or hemopericardium | 50 (2.3%) | NRa | 15 (8.6%) | 20 (7.5%) | <.001 |
| Cardiac arrest or CPR | 20 (0.9%) | NR | 20 (11.4%) | 15 (5.7%) | .002 |
| NSTEMI or type II MI | 25 (1.2%) | 20 (8.3%) | NR | NR | <.001 |
| Heart block | 25 (1.2%) | 15 (6.2%) | NR | NR | <.001 |
| Cardiogenic shock | 115 (5.4%) | 20 (8.3%) | NR | 15 (5.7%) | .321 |
| Any systemic complication | 30 (1.4%) | NR | NR | NR | .078 |
| Venous thromboembolism | 45 (2.1%) | NR | NR | NR | .024 |
| Septic shock | 25 (1.2%) | NR | NR | NR | .094 |
| Vascular complication | 80 (3.7%) | NR | NR | NR | <.001 |
| Retroperitoneal bleeding | 25 (1.2%) | NR | NR | NR | .231 |
| Neurological complications | NR | NR | NR | NR | <.001 |
| Any bleeding or hematological complication | 150 (7.0%) | 35 (14.6%) | 15 (8.6%) | NR | <.001 |
| Need for blood transfusion | 115 (5.4%) | 25 (10.4%) | NR | NR | <.001 |
| Any pulmonary complications | 245 (11.5%) | 30 (12.5%) | 25 (14.3%) | 15 (5.7%) | .015 |
| Respiratory failure | 170 (8.0%) | 25 (10.4%) | 15 (8.6%) | NR | .001 |
| Long-term ventilator use | 20 (0.9%) | NR | NR | 15 (5.7%) | .001 |
| Pneumonia bacterial | 60 (2.8%) | NR | NR | NR | .719 |
| Acute kidney injury | 355 (16.6%) | 80 (33.3%) | 45 (25.7%) | 70 (26.4%) | <.001 |
Values are n (%).
CPR, cardiopulmonary resuscitation; MI, myocardial infarction; NR, not reported; NSTEMI, non-ST-elevation myocardial infarction; T-TEER, tricuspid transcatheter edge-to-edge repair.
Data for n < 10 are not reported as per Healthcare Cost and Utilization Project recommendations.
Figure 2.
Inpatient outcomes after T-TEER by race and ethnicity. Forest plot depicting the independent association of race and ethnicity with mortality, major and overall complications, length of stay, and cost of hospitalization after tricuspid transcatheter edge-to-edge repair. White patients served as the reference group for all regression models.
Hospital outcomes and resource utilization
Hospital outcomes and resource utilization demonstrated significant racial and ethnic disparities as well (Table 3). In-hospital mortality was highest among Hispanic patients (4.5%) compared with White (2.0%) and Black (0.0%) patients. However, the adjusted multivariable logistic regression model showed no significant difference in odds of mortality for Hispanic patients (aOR, 1.13; 95% CI, 0.41-3.13) (Figure 2). Discharge to a health care facility was most common among Black patients (17.6%) compared with White (7.8%), and Hispanic (4.8%) patients (P < .01).
Table 3.
Inpatient outcomes and resource utilization in patients undergoing T-TEER, stratified by race or ethnicity.
| Variable | White (n = 2135, 75.8%) | Black (n = 240, 8.5%) | Hispanics (n = 175, 6.2%) | Other (n = 265, 9.4%) | P |
|---|---|---|---|---|---|
| Died at discharge | 30 (2.0%) | 0 (0.0%) | 5 (4.5%) | 10 (6.9%) | .017 |
| Discharge disposition | |||||
| Home discharge | 1360 (92.2%) | 140 (82.4%) | 100 (95.2%) | 130 (96.3%) | <.01 |
| Facility discharge | 115 (7.8%) | 30 (17.6%) | 5 (4.8%) | 5 (3.7%) | |
| Resource utilization | |||||
| Length of stay, d | 2.0 (1.0-5.0) | 6.0 (2.0-14.8) | 4.0 (2.0-6.0) | 2.0 (1.0-9.0) | <.01 |
| Cost of hospitalization, $ | 46,199.5 (34,318.6-67,001.7) | 54,306.2 (36,530.6-73,756.6) | 48,807.5 (34,067.1-57,415.2) | 52,143.2 (38,785.2-74,115.2) | <.01 |
Values are n (%) or median (IQR).
Black (mean: 6.0 days) and Hispanic (mean: 4.0 days) patients experienced longer hospital stays than White patients (mean: 2.0 days) (P < .01). This was also evident in the adjusted multivariable logistic regression model, which showed that Black (aOR, 2.47; 95% CI, 1.83-3.34) and Hispanic (aOR, 3.40; 95% CI, 2.36-4.90) patients have significantly higher odds of prolonged hospital stays than White patients (Figure 2). Hospitalization costs were higher for Black (mean: $54,306.20) and Hispanic ($48,807.50) patients than for White patients ($46,199.50) (P < .01). However, the adjusted multivariable logistic regression model showed no significant differences in hospitalization costs across racial and ethnic groups (Figure 2).
Discussion
In this study of 2815 patients undergoing T-TEER, we report several main findings (Central Illustration): (1) Black and Hispanic patients were younger on average but had higher rates of important comorbidities compared with White patients. (2) Black and Hispanic patients exhibited higher rates of major, overall, and cardiovascular complications compared with White patients; however, after adjustment, only Black patients retained significantly higher odds of major and overall complications compared with White patients. (3) Black and Hispanic patients experienced prolonged hospital stays compared to White patients; additionally, Black patients were also more likely to have non-home discharges to acute care facilities. (4) Mortality rates after T-TEER varied across racial and ethnic groups.
Central Illustration.
Key disparities in outcomes and complications of T-TEER by race and ethnicity. Black and Hispanic patients experienced greater in-hospital complication rates than their White counterparts, particularly cardiovascular, hematological, and renal complications. After adjusting for confounders, Black patients experienced greater odds of major complications; both Black and Hispanic patients had prolonged hospital stays compared with White patients. Black patients experienced greater rates of discharge to an acute health care facility. aOR, adjusted odds ratio; T-TEER, tricuspid transcatheter edge-to-edge repair.
Recent studies in the past decade have demonstrated important racial and ethnic disparities in the presentation and severity of valvular disorders. Echarte-Morales et al10 demonstrated that minority groups, especially Black and Hispanic patients, exhibited higher comorbidity burden and more advanced TR at time of initial evaluation than their White counterparts. Access to valvular interventions has also varied significantly between racial and ethnic groups. Black and Hispanic patients have been shown to be less likely than their White counterparts to undergo surgical mitral or tricuspid valve repair or replacement.11,12 Steitieh et al13 demonstrated geographic clustering of high-volume mitral transcatheter edge-to-edge repair centers that disproportionately served White patients, further indicating a structural barrier to access for minority groups. Our study further affirms systemic barriers in accessing advanced cardiac care among different race and ethnic groups. Notably, while Black and Hispanic individuals make up approximately 13.6% and 18.9% of the U.S. population, they represent only 8.5% and 6.2% of our study cohort, respectively.14 This underrepresentation underscores potential disparities in referral, access, or eligibility criteria that merit further investigation.
On the other hand, outcomes and mortality rates after valvular interventions have not shown consistent racial and ethnic disparities among minority groups. For example, Glance et al11 showed that Black patients who underwent surgical mitral valve repair or replacement had higher complication and mortality rates than their White counterparts. In contrast, Ismayl et al12 demonstrated that Black and Hispanic patients undergoing surgical tricuspid valve repair or replacement had similar in-hospital complications and mortality rates compared with their White counterparts. Prior studies have also shown similar in-hospital outcomes and mortality rates in transcatheter mitral valve replacement across racial and ethnic groups.13,15 Currently, limited data exist on potential racial and ethnic disparities regarding T-TEER outcomes. To our knowledge, our study is the first to identify significant racial and ethnic disparities in in-hospital outcomes and resource utilization among minority groups undergoing T-TEER.
In particular, Black and Hispanic patients undergoing T-TEER exhibited higher rates of major, overall, cardiovascular, hematological, and pulmonary complications compared with White patients. After adjustment, Black patients continued to have significantly higher odds of major and overall complications than White patients, whereas Hispanic patients did not. The higher burden of comorbid conditions in Black patients likely contributed to the reported disparities in complication rates. In-hospital mortality also varied across racial and ethnic groups, with the highest rate observed in Hispanic patients (4.5%) followed by White patients (2.0%), and no deaths were reported among Black patients. Although Black patients experienced significantly higher complication rates, they did not have an associated increase in in-hospital mortality. One possible explanation is that the complications were non-fatal but still clinically significant, leading to greater resource utilization. In particular, Black and Hispanic patients in our study experienced prolonged hospital stays compared with White patients, both before and after multivariable adjustment. This aligns with prior studies that demonstrated that minority groups had higher cost and LOS after valvular interventions than their White counterparts.12,16 Second, greater major and overall complications among Black patients likely corresponded to more frequent discharges to acute care facilities, such as skilled nursing or long-term acute care settings, compared with White and Hispanic patients (17.6% vs 7.8% and 4.8%, respectively). This pattern may reflect a shift in the location of care rather than a true absence of mortality risk, as deaths occurring after discharge are not captured in the NIS dataset.
In summary, our study contributes significantly to the ongoing discourse on health care equity, particularly highlighting disparities among structural cardiovascular interventions such as T-TEER. The data reveal that Black and Hispanic patients bear a disproportionately heavier burden in terms of complication rates and hospital stays compared with their White counterparts. However, the specific factors driving the observed racial and ethnic disparities after valvular interventions remain poorly studied. Additional research is crucial to uncover the underlying reasons for these disparities across racial and ethnic groups and to pinpoint opportunities for enhancing the quality and equity of interventional cardiovascular care, particularly among marginalized communities.
Limitations
Our study has several limitations; first, the NIS relies on administrative coding to identify diseases and procedures, which may be prone to errors. However, it is important to highlight that the NIS implements a strict data quality control program to reduce miscoding and maintain data integrity. Second, race and ethnic demographics in the NIS are often self-reported, self-described, or entered by clerks, which may introduce errors in classification. Additionally, the “Other” racial and ethnic group used in our study was composed of a composite of Asian-American, Pacific Islander, Native American, and multiracial patients. Due to sample size constraints, this subgroup was necessary but may represent a diversely heterogeneous population in which important subgroup differences may be masked. Third, the retrospective nature of the study introduces the potential for selection bias and limits the ability to draw causal inferences. Fourth, the NIS lacks validated risk scores such as the Society of Thoracic Surgeons score, which limits comprehensive risk assessment. Fifth, the database does not capture detailed baseline or procedural characteristics such as the cause of TR, echocardiographic data, valve anatomy, postprocedural residual TR, or discharge medications. These missing clinical variables may introduce unmeasured confounding bias and limit the interpretability of outcome differences. Sixth, as the NIS only includes data on inpatient stays, long-term outcomes and mortality after discharge cannot be assessed. Finally, although we adjusted for various demographic and clinical variables, the NIS provides limited granularity on social determinants of health, and other socioeconomic or structural inequities likely persist and remain unaccounted for in our analysis. Additionally, adjustment for hospital-level variables such as volume, teaching status, and geographic location was not feasible due to model constraints related to limited sample size and event frequency.
Conclusion
In conclusion, our study underscores significant racial and ethnic disparities in baseline characteristics, procedural complications, and hospital outcomes in patients undergoing T-TEER. Notably, Black patients, who are younger on average, bear a disproportionately higher burden of comorbidities and face greater risks of overall and major complications, even after adjusting for potential confounders. Similarly, Hispanic patients experienced longer hospital stays and a trend toward higher odds of overall complications and mortality, suggesting disparities in perioperative care and recovery. These findings highlight how clinical outcomes are intricately linked with socioeconomic factors, pointing to broader systemic inequities in the provision of advanced cardiac care. To bridge these gaps, there is an urgent need for further research to understand and address the root causes of these disparities. Policy reforms are essential to ensure equitable health care delivery and foster a more inclusive health care system for all patients.
Acknowledgments
Declaration of competing interest
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding sources
This work was not supported by funding agencies in the public, commercial, or not-for-profit sectors
Ethics statement and patient consent
The data from the NIS that was used in this study is deidentified and publicly available. Thus, the need for informed consent and institutional review board approval was waived.
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