Racial Disparities in Long-Term Outcomes After Endovascular Aortic Aneurysm Repair in Black and White Medicare Beneficiaries

Abstract

BACKGROUND: Despite reported racial disparities between Black and White adults in short-term outcomes after abdominal aortic aneurysmal intervention, there is a paucity of literature aimed at understanding long-term disparities. The present study aims to characterize racial disparities in long-term outcomes, perioperative outcomes, and health care use after endovascular aortic aneurysm repair. METHODS: We conducted a retrospective cohort study from 2011 to 2019 with outcome assessment through 2020. Using a 100% sample of national Medicare data, we identified beneficiaries ≥66 years of age who underwent intact infrarenal endovascular aortic aneurysm repair. The primary outcome was a composite of endovascular or open aortic reintervention, late aneurysm rupture, and all-cause mortality. Secondary outcomes included other reinterventions, perioperative outcomes, and annual rates of health care use. RESULTS: A cohort of 107 636 Black (3.9%) and White (96.1%) beneficiaries was identified. The cumulative incidence of the primary outcome was 72.9% (95% CI, 71.8%–73.9%) in White patients versus 80.0% (95% CI, 76.4–83.0) in Black patients ( P <0.0001). The adjusted hazard of the primary outcome was not significantly different between Black and White adults (adjusted hazard ratio [HR] 1.04 [95% CI, 0.99–1.09]); however, when death was treated as a competing risk, a significantly higher hazard for the composite outcome was observed for Black patients (subdistribution HR, 1.56 [95% CI, 1.39–1.76]). Components of the primary outcome were also greater among Black compared with White patients. Black patients had higher rates of medical complications in the perioperative period, including acute renal failure (subdistribution HR, 1.18 [95% CI, 1.01–1.38]), dialysis initiation (subdistribution HR, 2.75 [95% CI, 2.03–3.7]), and deep vein thrombosis (subdistribution HR, 1.54 [95% CI, 1.05–2.26]). Black patients had lower rates of vascular office visits after intervention (adjusted rate ratio, 0.96 [95% CI, 0.93–0.99]) but higher rates of emergency department visits (adjusted rate ratio, 1.05 [95% CI, 1.02–1.09]) and hospital readmissions (adjusted rate ratio, 1.13 [95% CI, 1.08–1.18]). CONCLUSIONS: Black patients demonstrated increased risk of late aortic-related events after endovascular aortic aneurysm repair after accounting for the competing risk of death and controlling for baseline covariates. Further investigation into structural barriers affecting optimal preoperative medical management and barriers to postoperative health care access is necessary to further elucidate underlying mechanisms for the observed disparities.