A systematic review with meta-analysis on racial and ethnic disparities in acute venous thromboembolism diagnosis and management

Abstract

Objective

Acute venous thromboembolism (VTE), encompassing deep vein thrombosis and pulmonary embolism, is one of the leading causes of cardiovascular mortality. Recent studies have shown racial and ethnic disparities in VTE incidence and outcomes. The objective of this review is to identify racial and ethnic disparities present in the incidence, diagnosis, and management of VTE.

Methods

A comprehensive review was conducted in PubMed and ScienceDirect using the following search terms: pulmonary embolism, deep vein thrombosis, race, ethnicity, racial disparities, ethnic disparities, and social determinants. Papers were included if they were published in English and within the years 2004 to 2024. Papers were excluded if they studied non-United States adult populations, if VTE was not a main outcome of interest, or if they focused on surgery or COVID-related VTE. The resultant papers (n = 52) included randomized clinical trials, systematic reviews, meta-analyses, and observational studies at single-center, multi-center, and national levels. Quantitative data on the use of catheter-based therapies (CBTs) by racial and ethnic groups were extracted from a subsect of papers where it was explicitly reported (n = 8). Using this data, a meta-analysis was conducted to compare the utilization of CBTs for pulmonary embolism across different racial and ethnic groups.

Results

Significant racial and ethnic disparities in the diagnosis and treatment of VTE were noted. Black patients had the highest disease incidence, severity, mortality, and inpatient complications. Similar inequities may exist among other racial and ethnic groups, although these remain less well-characterized due to limited ethnic representation in current VTE literature and related clinical trials. Genetic factors contribute more to VTE risk in White patients, whereas comorbidities and socioeconomic disparities have a more significant impact on non-White patients. Several studies have noted disparities in access to catheter-directed thrombolysis for non-White patients compared with White patients. Notably, racial disparities in advanced therapy usage are reduced in the context of high-risk pulmonary embolism, though ethnic disparities persist. Initial studies have suggested that Pulmonary Embolism Response Team implementation may reduce disparities in VTE management, though further research is needed to evaluate its impact on outcomes. Results of the meta-analysis further supported these findings by revealing increased CBT usage in White and non-Hispanic patients compared with Black and Hispanic patients, respectively.

Conclusions

Socioeconomic vulnerability and comorbid conditions account for disparities in VTE incidence in minority populations, and poor outcomes in these groups may be tied to inequalities in access to catheter-based interventions.

Acute venous thromboembolism (VTE) encompasses acute deep vein thrombosis (DVT) and acute pulmonary embolism (PE). These thrombotic events occur under a set of physiological pretenses dictated by Virchow’s Triad: Damage to the endothelial lining, a hypercoagulable state, and blood stasis. In the context of DVT, thrombosis occludes venous blood flow in the extremities, causing pain and swelling. The resultant venous wall inflammation and increased venous shear stress may induce phlebosclerosis, leading to post-thrombotic syndrome (PTS), and increased risk of recurrence.¹ PE is a potentially fatal condition caused by thrombus embolization and obstruction of pulmonary arterial circulation, increasing pulmonary vascular resistance and strain on the right ventricle (RV), ultimately reducing cardiac output, and predisposing patients to cardiopulmonary and hemodynamic decompensation.² Several vascular and hematologic conditions predispose to the development of VTE by worsening one or more of the factors from Virchow’s triad (Table I).

Table I.

Venous thromboembolism (VTE) predisposing conditions grouped by Virchow’s triad

Condition	Mechanism
Damage to the endothelial lining
Venous compression syndromes (eg, May-Thurner, Nutcracker, Paget-Schroetter syndromes)	Increased shear stress on vascular intima causing endothelial dysfunction3
Sickle cell disease	Intravascular hemolysis causes inflammatory response leading to endothelial dysfunction4
Hypercoagulable state
Inherited thrombophilia (eg, prothrombin mutations, factor V Leiden, protein C/S deficiencies, etc)	Heritable overactivation of coagulation cascade3,5
Acquired thrombophilia (eg, antiphospholipid syndrome)	Overactivation coagulation cascade secondary to an underlying pathology3,5
HIV	Lower concentration of coagulation cascade inhibitors (eg, protein C/S, antithrombin III)6 Increased expression of tissue factor on monocytes6
Obesity	Excess adipose tissue releases proinflammatory molecules that increase levels of procoagulant factors in circulation6
Venous stasis
Obesity	Pressure from excess adipose weakens vessel walls, resulting in blood stasis7

This table provides an overview of risk factors for VTE and how they contribute to pathogenesis. There are citations included for each stated observation.

Clinical presentation

VTE affects approximately 900,000 individuals annually in the United States (U.S.), with 60,000 to 100,000 deaths attributed to its complications.⁸ As the third leading cause of cardiovascular mortality after coronary artery disease and stroke, VTE-related hospitalizations and deaths are increasing.⁹ Notably, racial and socioeconomic disparities influence survival rates, with studies highlighting higher mortality among Black patients.10, 11, 12, 13, 14, 15 Black patients exhibit the highest incidence of both provoked and unprovoked DVT, as well as hospital-associated PE.⁷,¹⁶,¹⁷ This population also experiences increased hospitalization rates, readmission rates, longer length of stay (LOS), and higher mortality, with studies reporting up to 41% greater risk of death from acute PE compared with White patients, regardless of treatment modality.^10,18, 19, 20 Despite advancements in catheter-based therapies (CBTs) and ongoing efforts to address health care inequities, this elevated mortality trend persists,^21,22 reinforcing substantial evidence of racial disparities in VTE outcomes.

VTE trends among other minority populations—including Hispanic, Asian/Pacific Islander, and Native American patients—are less consistently reported. Many studies categorize these groups under a broad “other” classification, historically suggesting lower VTE incidence and mortality compared with Black and White populations.⁷,¹⁶,^17,23, 24, 25, 26 However, recent analyses challenge this notion, demonstrating higher VTE-related mortality in Hispanic and Asian/Pacific Islander patients than in White patients.¹⁰ Similarly, Snyder et al found that Hispanic patients exhibited lower PE case severity but comparable mortality rates, potentially indicating systemic disparities in VTE management.²⁷ These findings underscore the need for more granular research into ethnic variations in VTE burden and treatment outcomes.

General overview of deep vein thrombosis management

The primary treatment of acute DVT is an outpatient medical therapy with anticoagulation, most commonly using agents such as direct oral anticoagulants (dabigatran, apixaban, rivaroxaban), low molecular weight heparin, or fondaparinux, followed by warfarin.²⁸ Advanced interventions may be warranted in patients with high symptom burden or high likelihood of recurrence.^28,29 Iliofemoral DVT, due to its significant symptom burden and high risk of PTS, is the most frequent indication for invasive therapy.^29,30 These patients have significantly improved disease-related quality of life and PTS severity following intervention.^30,31 However, in most cases, interventions are typically avoided as they have not shown significant improvement in outcomes compared with anticoagulation alone.^28,29

General overview of pulmonary embolism management

The management of PE depends on risk stratification, ranging from anticoagulation alone for low-risk PE to advanced therapies for hemodynamically unstable patients. Similar to DVT treatment, patients with low-risk PE are treated with anticoagulation alone. More symptomatic cases require hospital admission and diagnostic imaging to assess disease severity. Elevated troponins or evidence of RV dysfunction is considered intermediate to low risk, whereas the presence of both is classified as intermediate to high risk.32, 33, 34 Management of patients with intermediate-risk PE is more variable, incorporating anticoagulation with catheter-based intervention, and, to a lesser extent, systemic thrombolysis (ST) in carefully selected patients. Patients with PE and hemodynamic instability are defined as high-risk PE. These patients require immediate intervention, with ST or CBTs to rapidly restore pulmonary perfusion and relieve RV strain.^28,32

Current VTE guidelines are based on clinical trials conducted in White patients, raising concerns about their applicability to diverse populations. A recent review of trials reporting race and ethnicity found that 96.3% of the total patient population was White, whereas only 2.1% were Black, 1.4% were Asian, and just 0.25% were Hispanic.³⁵ This highlights the under-representation of ethnic minorities in the clinical trials that shape the current guidelines for VTE treatment, suggesting more inclusive research to improve equitable treatment recommendations to ethnically diverse patient populations (Fig 1).

Fig 1.

Catheter-based therapy (CBT) usage by race and ethnicity. This figure provides a qualitative summary of the CBT usage by race and ethnicity as reflected in the included literature. CBT usage was more commonly utilized in White and non-Hispanic patients compared with Black and Hispanic patients respectively, highlighting both racial and ethnic disparities in utilization of advanced therapies.

In summary, these disparities underscore systemic gaps in VTE diagnosis and management, necessitating targeted efforts to improve equitable care. This review aims to explore the ethnic and racial disparities in VTE diagnosis, treatment, and outcomes, emphasizing avenues for reducing clinical bias and optimizing patient care.

Methods

To identify studies to include or consider for this systematic review, the review team developed a detailed search strategy for both PubMed and Science Direct, as detailed in Fig 2. Terms included in the initial search strategy with title/abstract filter include “race, racial disparities, ethnicity, ethnic disparities, or social determinants” in conjunction with “pulmonary embolism or deep vein thrombosis.” The results from both searches were entered into EndNote citation manager to identify and remove duplicate records. The remaining papers were narrowed to only include studies published within 2004 to 2024, U.S.-based studies, and studies reported in English. The remaining studies underwent an abstract screen wherein they were evaluated by the following inclusion criteria: (1) the paper must focus on adult populations; (2) the study must focus on U.S. populations; and exclusion criteria: (1) VTE is not the main outcome of interest; (2) the paper focuses on surgery-related VTE; and (3) the paper focuses on COVID-related VTE. The decision was made to exclude surgery and COVID-related VTE due to the presence of confounding variables, such as adequate prophylaxis and pandemic-associated disparities.

Fig 2.

Identification of studies via database searches. This figure provides an overview of the search strategy used to identify studies for the narrative review. This selection was further evaluated using inclusion and exclusion criteria to identify studies eligible for our subsequent meta-analysis. CBT, Catheter-based therapy; U.S., United States; VTE, venous thromboembolism.

All resultant papers (n = 52) were synthesized for production of the manuscript. Of these 52 papers, eight underwent a further quantitative analysis comparing usage of CBTs in different races and ethnicities. Studies were deemed eligible for this analysis if they reported quantitative data on patient demographics and CBT usage by race or ethnicity. All eight included studies were used for the racial analysis; however, only six reported on ethnicity. The included studies are detailed in Table II. Of these eight studies, those that included quantitative data on the distribution of high-risk vs non–high-risk PE by race and ethnicity were further extracted for a subanalysis on disease severity (n = 4). This systematic review and meta-analysis were conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. A completed PRISMA checklist is provided in the Supplementary Materials (online only).

Table II.

Reported usage of catheter-based techniques (CBTs) by race and ethnicity

Study	Total patients					Patients receiving CBT				Patients receiving Non-CBT
	Total no. patients	Total no. White patients	Total no. Black patients	Total no. non-Hispanic patients	Total no. Hispanic patients	White CBT patients	Black CBT patients	Non-Hispanic CBT patients	Hispanic CBT patients	White non-CBT patients	Black non-CBT patients	Non-Hispanic non-CBTpatients	Hispanic non-CBT patients
Breuer et al	13,757	10,143	2576	12,867	890	5544	1287	6899	430	4599	1289	5968	460
Synder et al	1265	557	367	791	474	57	43	89	31	500	324	702	443
Rush et al	387,514	264,522	68,953	361,540	25,974	9906	2621	13,447	802	254,616	66,332	348,093	25,172
Matusov et al	113	65	38	105	7	27	11	39	3	38	27	66	4
Bashir et al	129,445	95,702	26,547	122,278	7167	4133	1080	5213	293	91,569	25,467	117,065	6874
Phillips et al	4474	3264	1210	–a	–a	169	35	–a	–a	3095	1175	–a	–a
Dronamraju et al	425	131	294	–a	–a	21	33	–a	–a	110	261	–a	–a
Rehman et al	290	163	115	266	24	25	24	52	1	138	91	214	23

This table provides all raw data of studies included in the meta-analysis.

Non-CBT = Systemic thrombolysis, surgical thrombectomy, inferior vena cava filter, or anticoagulation alone.

^aTreatment usage was not studied in Hispanic patients.

Statistical analysis

A meta-analysis was conducted to compare the utilization of CBTs for PE across different racial and ethnic groups. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated for each individual study to quantify the associations between race/ethnicity and CBT utilization. Separate common-effect Mantel-Haenszel models were employed to pool the study-specific effect estimates for each comparison. This approach assumes a single true effect size across all studies and weights each study by the inverse of its variance. Publication bias was assessed visually using funnel plots and statistically using Begg’s rank correlation test. Analyses were conducted separately for race (White vs Black) and ethnicity (Non-Hispanic vs Hispanic) comparisons. A two-tailed P-value < .05 was considered indicative of significant publication bias. Statistical significance of the pooled effects was determined using z-tests with a two-tailed P-value threshold of .05. Stata 19 (StataCorp) was used to conduct meta-analysis.

Results

Risk factors: genetic causes

Genetic predisposition plays a significant role in VTE risk, with studies estimating 50% to 60% of cases attributable to hereditary factors.^21,22,36,37 Traditionally, higher VTE incidence in Black patients has been associated with sickle cell disease, whereas in White populations, it has been linked to Factor V Leiden mutation, prothrombin gene mutations, and non-O blood type (Table I).^21,38,39 In contrast, Eastern populations exhibit a higher prevalence of Protein C/S and antithrombin deficiencies, although these risk factors remain understudied in the U.S.⁴⁰

Initially, racial disparities in VTE incidence were thought to stem from genetic differences; yet further studies indicate that White populations have a higher prevalence of these genetic risk factors, whereas Black patients experience 65% higher VTE incidence despite lower genetic predisposition.^21,22,39,41 Alternative risk factors, including higher body mass index, lower family income, and elevated Factor VIII levels, have been implicated in increased VTE susceptibility among Black patients, suggesting a multifactorial interplay of genetic and environmental influences.³⁹

Risk factors: lifestyle causes

Social determinants of health, including advanced age, female gender, lower income, Medicaid insurance, and urban residency, are strong predictors of PE mortality.⁴² Farmakis et al found higher prevalence of these factors in non-White ethnic groups, with the only two exceptions being Asians and Pacific Islanders, who have, on average, higher income, and Native Americans, who reside more in rural areas.⁴² Socioeconomic vulnerability, including insurance status and household income, has emerged as the most influential determinants of VTE outcomes and treatment.^10,13,42,43

Several studies have explored the intersection of race and insurance coverage, consistently noting similar trends in VTE morbidity, mortality, and access to interventional therapies.³,^10,42 Notably, Breuer et al demonstrated that racial disparities in VTE mortality could largely be accounted for by insurance status, reinforcing the hypothesis that health care access, rather than race alone, plays a significant role.¹⁰ These findings emphasize the multifactorial nature of VTE mortality, highlighting systemic barriers to care that disproportionately affect minority populations.

Risk factors: acquired conditions

Certain acquired conditions increase an individual’s VTE risk, including cancer, HIV, obesity, and prior VTE. Except for cancer, these are generally more common in non-White ethnicities, which may point to increased susceptibility to VTE in these groups.²⁴ The impact of comorbidity on VTE risk is often enhanced in non-White patients, as seen with cancer-associated thrombosis, where Black patients with cancer have a higher incidence and mortality, irrespective of cancer staging, age, sex, or body mass index.44, 45, 46, 47 Similarly, obesity—a known VTE risk factor contributing to up to 30% of VTE cases—is a stronger predictor of VTE risk in Hispanics compared with White individuals.^41,48 Additionally, Black patients with congestive heart failure or atrial fibrillation show higher VTE rates than their White counterparts.³,^39,49

Diagnosis: clinical assessment tools

Clinical decision-making for VTE diagnosis has largely been streamlined with the introduction of scoring systems designed to assess VTE risk, such as the Wells score, Geneva score, Caprini score, and Khorana score.^28,50, 51, 52 Although these tools are widely used, their generalizability and predictive accuracy across diverse racial and ethnic groups remain largely unexplored. A recent study showed significant disparity in the accuracy of the Khorana score in predicting VTE in Black patients as compared with White patients, despite their higher incidence of disease.⁴⁴ These findings underscore the need for standardizing the race-inclusive assessment tools, which could improve early detection and tailored interventions, ultimately optimizing patient outcomes across all racial groups (Fig 3).

Fig 3.

Trends in venous thromboembolism (VTE) risk factors and diagnostic protocols by race. This figure summarizes the most prevalent risk factors for VTE by race and ethnicity, illustrating that Black patients demonstrate the highest overall risk and White patients the least. This figure also summarizes current disparities in the VTE diagnostic protocol including risk assessment, D-dimer testing, and imaging. AF, Atrial fibrillation; CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease.

Diagnosis: D-dimer testing

Clinical risk assessment tools are often supplemented with D-dimer testing to evaluate patients for VTE presence. Although low D-dimer levels are a reliable marker for the absence of VTE, high levels do not have a high positive predictive value.⁵³ D-dimer levels and other serum markers of hypercoagulability and infammation have consistently been observed at higher concentrations in Black populations.^38,54 However, this observation has not been directly linked to the heightened VTE incidence in this population.⁵⁴ Therefore, it is plausible that implementation of D-dimer testing in VTE diagnosis may lead to overdiagnosis or misclassification of Black patients. Further investigation is warranted to determine whether D-dimer thresholds should be adjusted for racial variations to enhance diagnostic accuracy while preventing unnecessary intervention (Fig 3).

Diagnosis: imaging

Imaging is a critical component in confirming VTE diagnoses, particularly in high-risk patients. Doppler ultrasound imaging has become the cornerstone for DVT imaging. For Patients with suspected PE, computed tomography pulmonary angiography or ventilation/perfusion scans (when computed tomography pulmonary angiography is contraindicated) are the preferred modalities. Despite the widespread use of these imaging modalities, the diagnostic yield has remained unchanged, prompting a recent advisory statement cautioning against overutilization due to potential complications such as increased lifetime risk of cancer, nephropathy, and patient anxiety.^53,55, 56, 57

Despite these recommendations, imaging overuse persists in clinical practice, even among low-risk patients. A single-center study found that 25.5% of emergency department patients classified as low risk by Pulmonary Embolism Rule Out Criteria still underwent additional imaging, with a diagnostic yield of only 1.6%.⁵⁸ Asian and Hispanic patients exhibit the lowest diagnostic yield and are therefore most vulnerable to unnecessary testing.⁵⁹ Although diagnostic yield is higher in White and Black patients, additional screening has not been found to improve outcomes.⁵⁸ These findings suggest that VTE screening practices are generally adequate—if not excessive—across all racial groups, making it unlikely that imaging access is a primary factor contributing to disparities in VTE outcomes (Fig 3).

Treatment: systemic thrombolysis

ST involves the intravenous administration of fibrinolytic agents, most commonly alteplase or urokinase, to facilitate pharmacologic thrombus dissolution. ST is the first-line therapy for patients with high-risk PE and no contraindications to fibrinolytics. It rapidly reduces clot burden, improving RV function and mortality, particularly when administered within an appropriate time frame, defined in one study as 8.5 hours from symptom onset.^34,60,61 Although its use in intermediate-risk PE has also shown benefits in RV function, ST is generally avoided outside of high-risk PE due to the high risk of major bleeding complications, including a 2% to 3% risk of intracranial hemorrhage.^62,63 Further studies are needed to fully establish the efficacy of ST therapy over alternatives for intermediate-risk groups, especially given the advent of new catheter-based interventions. With respect to acute DVT, ST is currently not recommended.

Preliminary studies highlight racial and socioeconomic disparities in the usage of ST and outcomes. Patients of lower socioeconomic status are less likely to receive ST and have higher rates of 90-day readmission and 1-year mortality from VTE.⁴³ This suggests that socioeconomically vulnerable patients lose out on the long-term benefits associated with ST therapy, potentially contributing to a higher disease burden in this population. Studies have shown that among patients undergoing PE intervention, there was no difference in ST usage by race.⁶⁴ However, White male patients were more likely to receive newer CBTs with improved safety profiles, translating into lower rates of major bleeding and LOS in this group.⁶⁴ These trends reflect that, although ST remains commonly used for patients with high-risk PE, the use of CBTs has been rising and yet seemingly underused in non-White populations^64,65 (Fig 1).

Treatment: catheter-directed thrombolysis

Catheter-directed thrombolysis (CDT) emerged as a strategy to minimize the bleeding complications of ST by localizing the administration of low-dose fibrinolytic agents via catheter. Its effectiveness over anticoagulation alone has been demonstrated in iliofemoral DVT, where it has been shown to reduce the severity of acute symptoms and reduce the severity of PTS in the long term.^29,66 CDT has also demonstrated clinical benefit in acute PE, improving mortality rates and long-term RV function compared with anticoagulation alone.^34,63,67,68 These benefits have increased CDT utilization in intermediate PE cases.^28,65 Within the context of high-risk PE, there are concerns that RV strain is reduced at a rate too slow to address hemodynamic instability immediately; therefore, ST remains the preferred modality.^65,69

Despite the rapid adoption of CDT, racial and ethnic disparities persist. Several nationwide studies have revealed that non-White patients are less likely to receive CDT by as much as 17% to 29%.^10,18,28,70 Moreover, studies have identified that non-White patients experience longer delays to intervention, with Black patients in particular having longer LOS and incurring higher hospital costs.^28,67,71 Importantly, a supplementary pooled analysis of the included studies examined the prevalence of high-risk PE by race and ethnicity. Black patients had significantly higher odds of presenting with high-risk PE compared with White patients (pooled OR, 0.84; 95% CI, 0.81-0.86; P < .001; k = 4 studies), and Hispanic patients had higher odds compared with non-Hispanic patients (pooled OR, 0.78; 95% CI, 0.75-0.81; P < .001; k = 2 studies). Less frequent usage of CBTs in Black and Hispanic patients may, in part, be explained by these trends in disease severity, as ST remains most used for high-risk patients. However, CBTs are being more widely used in higher risk cases. Therefore, the observed disparities in CDT utilization cannot be solely attributed to differences in presenting disease severity and instead implicate socioeconomic and systemic barriers as substantial drivers of unequal access to advanced therapies.

Treatment: percutaneous mechanical thrombectomy

Percutaneous mechanical thrombectomy (PMT) is an alternative intervention for patients with absolute thrombolytic contraindications, using catheters to extract the thrombus⁷² mechanically. Methods of extraction include suction/aspiration, rheolytic, and rotational thrombectomy.⁷³

In comparing CDT and PMT, mortality rates and major bleeding rates, including intracranial hemorrhage rates, are similar.⁷⁴ Despite promising results, preliminary studies on PMT remain limited, leaving gaps in understanding its racial and ethnic disparities in utilization and outcomes. The frequent under-representation of minority populations in randomized clinical trials evaluating emerging therapies underscores the urgent need for more inclusive research to determine whether PMT accessibility and benefits are equitably distributed across diverse patient groups.³⁵

Treatment: pharmacomechanical catheter-directed thrombolysis

Pharmacomechanical catheter-directed thrombolysis (PM-CDT) integrates the mechanical disruption of thrombi with localized administration of low-dose thrombolytics, combining the advantages of CDT and PMT.⁷⁵ This approach enhances clot exposure to fibrinolytic agents, improving dissolution efficiency while minimizing systemic bleeding risks.⁷⁵ The RESCUE study demonstrated that PM-CDT with the Bashir endovascular catheter caused a 33% reduction in RV/left ventricle ratio and a 35.9% reduction in pulmonary artery obstruction within 48 hours, with less than 1% major bleeding rate. In this study, 42% of the patients enrolled were non-White.⁷⁶ Similar benefits have been noted in iliofemoral DVT.^30,77 Despite promising results, there remains a lack of literature examining potential racial and ethnic disparities in PM-CDT usage and outcomes.

Role of Pulmonary Embolism Response Teams

In recent years, institutions have established multidisciplinary Pulmonary Embolism Response Teams (PERTs), to optimize the management of acute PE.⁷⁸ Many studies have suggested that PERT implementation decreases the time to PE triage, diagnosis, and anticoagulation or interventions; however, reports have been inconsistent regarding whether these improvements lead to decreased mortality rates.79, 80, 81 Further studies with larger datasets and long-term follow-up are needed to fully evaluate the benefit of PERTs on PE outcomes.

Beyond clinical efficiency, PERTs may also play a role in reducing racial disparities in PE management. Studies from safety-net hospitals have reported that PERT implementation led to equal access to advanced interventional therapies across racial groups.^78,82,83 These findings underscore the potential of PERT models to minimize bias in clinical decision-making, making them a promising avenue for achieving more equitable PE care. Further research is warranted to evaluate long-term outcomes and refine PERT protocols to ensure maximal benefit across diverse patient populations.

Race comparison: White vs Black patients

The race-stratified meta-analysis included eight studies comprising 374,547 White patients and 100,00 Black patients. Among White patients, 19,882 received CBT and 354,665 did not. Among Black patients, 5134 received CBT and 94,966 did not. Individual study ORs ranged from 0.69 (95% CI, 0.37-1.28) to 1.83 (95% CI, 1.27-2.65), demonstrating considerable variability across studies. The largest study by Rush et al (n = 333,475) showed an OR of 0.98 (95% CI, 0.94-1.03) and contributed 59.78% of the overall weight. Several smaller studies demonstrated increased odds of CBT use among White patients, including Phillips et al (OR, 1.83; 95% CI, 1.27-2.65) and Matusov et al (OR, 1.74; 95% CI, 0.74-4.11). The pooled analysis revealed that White patients had statistically significantly higher odds of receiving CBTs compared with Black patients (OR, 1.04; 95% CI, 1.01-1.08; z = 2.36; P = .02), although the magnitude of this difference was modest (Fig 4).

Fig 4.

Meta-analysis of catheter-based therapy (CBT) usage for pulmonary embolism (PE) by race and ethnicity. This figure demonstrates forest plots created by our biostatistician illustrating the quantitative results of our analysis comparing CBT usage by race and ethnicity. The studies included for this analysis and their raw data are reported. CI, Confidence interval.

Ethnicity comparison: Hispanic vs non-Hispanic patients

The ethnicity-stratified meta-analysis included six studies comprising 890 Hispanic patients and 354,966 non-Hispanic patients. Among Hispanic patients, 1560 received CBT and 32,976 did not. Among non-Hispanic patients, 25,739 received CBT and 472,108 did not. Individual study ORs ranged from 0.79 (95% CI, 0.17-3.71) to 5.59 (95% CI, 0.74-42.34), with most studies demonstrating increased odds of CBT use among non-Hispanic patients. The largest study by Rush et al (n = 361,540) showed an OR of 1.21 (95% CI, 1.13-1.30) and contributed 60.46% of the overall weight. The pooled analysis demonstrated that non-Hispanic patients had statistically significantly higher odds of receiving CBTs compared with Hispanic patients (OR, 1.19; 95% CI, 1.12-1.26; z = 6.08; P < .001), indicating an approximately 19% increased odds of CBT utilization (Fig 4). Funnel plot analysis for the race-stratified comparison (White vs Black, k = 8 studies) demonstrated symmetric distribution around the pooled effect estimate (Fig 5, A). Begg’s rank correlation test confirmed no evidence of publication bias (P = 1.00). For the ethnicity-stratified comparison (non-Hispanic vs Hispanic, k = 6 studies), the funnel plot showed symmetric distribution (Figure 5, B), and Begg’s test was not statistically significant (P = .71). These findings suggest that the pooled estimates are unlikely to be substantially influenced by publication bias.

Fig 5.

(A) Funnel plot of publication bias in ethnicity-stratified analysis. This figure visually represents the results of our pooled effect estimates and Begg’s rank correlation test in assessing publication bias for studies included in the race arm of our meta-analysis. (B) Funnel plot of publication bias in ethnicity-stratified analysis. This figure visually represents the results of our pooled effect estimates and Begg’s rank correlation test in assessing publication bias for studies included in the ethnicity arm of our meta-analysis. CI, Confidence interval.

Discussion

Both race and ethnicity were associated with differential utilization of CBTs for pulmonary embolism. Non-Hispanic patients demonstrated notably higher odds of CBT utilization compared with Hispanic patients (19% increase), whereas White patients showed a modest but statistically significant increase in CBT use compared with Black patients (4% increase). These findings suggest potential disparities in the application of advanced PE treatment modalities across racial and ethnic groups. Addressing racial and ethnic disparities in VTE outcomes requires systematic efforts to tackle the socioeconomic barriers that hinder access to health care and preventive measures. Future research should focus on.

• •Validating risk assessment models across diverse populations to improve diagnostic accuracy;
• •Expanding clinical trials to include a greater representation of minority patients in evaluating newer catheter-based interventions;
• •Standardizing treatment protocols to ensure equitable access to low-risk and advanced therapies;
• •Investigating clinician biases and institutional barriers that contribute to disparities in intervention selection; and
• •Assessing the role of PERT models in reducing inequities in PE management and determining their impact on long-term patient outcomes.

Limitations

This review has several limitations that must be acknowledged. Much of the current literature on racial and ethnic disparities in VTE diagnosis and management is derived from retrospective, observational, or administrative database studies. Such designs are inherently limited by selection bias, incomplete data, and variability in data quality. Consequently, the associations reported between race, socioeconomic status, and VTE outcomes should be interpreted as correlative rather than causal. Although a structured literature search was conducted, potential bias may exist in the selection of included studies and data extraction. Although publication bias assessment using funnel plots and Begg’s rank correlation test revealed no significant bias for either racial (P = 1.0) or ethnic (P = .71) comparisons, the relative small number of included studies (k = 8 for race, k = 6 for ethnicity) may limit the sensitivity of these tests to detect subtle asymmetry. Efforts were made to include the most relevant and high-quality studies; however, potential publication bias and heterogeneity in study designs may limit the comprehensiveness of this synthesis.

Another limitation is that most data analyzed were derived from inpatient populations, which may not accurately reflect outpatient- or community-based trends. Furthermore, studies focusing on provoked VTE were not included, thus limiting the ability to extrapolate these findings to all VTE subtypes. Many studies also reported race and ethnicity inconsistently, often grouping minorities under “other” or omitting groups such as Hispanic patients, which further reduces accuracy and generalizability of findings. Moreover, many studies did not adequately adjust for social determinants of health, therefore increasing the risk of confounding bias.

Of the studies included for the meta-analysis, only four papers were eligible for the high-risk PE incidence by race analysis and only two were eligible for the analysis by ethnicity. Although the results of this analysis did show statistically significant difference in incidence by both race and ethnicity, future investigations with more studies is needed to more strongly confirm these findings. Despite these limitations, the large cumulative sample size across studies strengthens the reliability and generalizability of observed trends.

Conclusions

Non-White patients experience more frequently experience disparities in care for acute VTE compared with White patients. Black patients have been shown to suffer higher PE incidence and morbidity owing to the multifactorial impact of social determinant inequities in increasing risk. Trends in PE incidence and outcomes among other non-White U.S. ethnicities are less differentiated due to a lack of adequate representation in observational studies and clinical trials, demonstrating a need for more diverse sampling. With regard to treatment, CBTs with improved safety profiles are more commonly utilized in White patients compared with non-White patients. A multidisciplinary, equity-focused approach to VTE prevention, diagnosis, and treatment will be critical in closing the gap in racial disparities and ensuring better outcomes across all patient populations.

Author Contributions

Conception and design: RB

Analysis and interpretation: MA, SJ

Data collection: MA, SJ

Writing the article: MA, SJ

Critical revision of the article: SJ, RB

Final approval of the article: MA, SJ, RB

Statistical analysis: Not applicable

Obtained funding: Not applicable

Overall responsibility: MA

Funding

None.

Disclosures

None.