Regarding “Thoracic endovascular aneurysm repair, race, and volume in thoracic aneurysm repair”

Abstract

We read with great interest the article by Goodney et al1Goodney P.P. Brooke B.S. Wallaert J. Travis L. Lucas F.L. Goodman D.C. et al.Thoracic endovascular aneurysm repair, race, and volume in thoracic aneurysm repair.J Vasc Surg. 2013; 57: 56-63Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar in the January 2013 issue of the Journal of Vascular Surgery. The authors tackle the complex and troubling problem of race and health care outcome and identify race-correlated disparities in access to high-volume surgical centers as a potential contributor to higher postoperative mortality among black patients. This is an important insight, and one that should be of concern for health care resource planning as health care reform moves forward. The authors go on to comment that, although clear volume effects are apparent for race and open surgical mortality—low volume being associated with both—no such effects are present for thoracic endovascular aortic repair (TEVAR). Furthermore, the authors show that TEVAR patients of white and black race have nearly identical mortality curves during 5 years of follow-up, and indeed, the log-rank test shows no difference between the groups (P < .563). From this, they conclude that TEVAR may produce less racial disparity in outcome. Unfortunately, elimination of the racial disparity in survival seems to be accomplished by reducing 5-year survival in white and black patients alike. At year 5 in the surgery group, survival is 71% for whites and 61% for blacks, whereas in the TEVAR group, it appears to be ∼56% for both whites and blacks. The authors do say in the Results that “Overall, patients with intact TAAs selected for TEVAR had poorer 5-year survival….,” implying that the higher 5-year mortality rate is merely a selection effect, but we do not see a test of selection to TEVAR in the report. Moreover, survival at 30 days is comparable between TEVAR and open repair patients (93.9% vs 92.9%, respectively; P = .563), which suggests that the poorer outcome in TEVAR patients occurred later in the postoperative course than in the perioperative period. No information on postoperative events, such as reinterventions, that might assist in interpreting the steeper late mortality slope is presented. Taken at face value, the results of their report suggest that the way to reduce racial disparities in outcome is to offer an inferior treatment to everyone. Without more actual information on preoperative characteristics that would suggest a selection bias—or late reinterventions that might suggest a stormy late course—it is impossible to tell why everyone did worse with TEVAR. Based solely on the data presented, it is difficult to see any support for a recommendation that TEVAR is a preferred strategy for the reduction of race-correlated outcome disparities. Thoracic endovascular aneurysm repair, race, and volume in thoracic aneurysm repairJournal of Vascular SurgeryVol. 57Issue 1PreviewVolume-based disparities in surgical care are often associated with poorer results in African American patients. We examined the effect of treatment patterns and outcomes, by race, for isolated thoracic aortic aneurysm (TAA). Full-Text PDF Open ArchiveReplyJournal of Vascular SurgeryVol. 59Issue 2PreviewWe appreciate the editorialist's interest in our manuscript and our findings. The editorialist makes two very accurate assertions: (1) that long-term survival is inferior among all patients undergoing thoracic endovascular aortic repair (TEVAR), both black and white, and (2) deaths occurring after 30 days appear to drive the long-term difference in survival between patients selected for open repair and patients selected for TEVAR, an effect that is again independent of race. Full-Text PDF Open Archive