Patients who are female, black, Asian or less well-off are significantly less likely to be offered heart valve surgery on the NHS in England, according to a report that experts say is “deeply concerning”.
People develop aortic stenosis when their aortic valve narrows as a result of calcium buildup, impeding normal blood flow. This causes shortness of breath, light headedness and chest pain.
Aortic valve replacement (AVR) surgery not only relieves these symptoms but increases life expectancy and improves quality of life. As many as one in four of those with severe or very severe aortic stenosis will die within five years without AVR.
However, a large analysis examining AVR on the health service in England – the first of its kind – reveals striking inequalities in its provision.
Women, black and Asian people, and those living in the poorest parts of the country are much less likely to receive the life-saving procedure, the study shows. The findings were published in the open access journal Open Heart.
“In this large, national dataset, female gender, black or south Asian ethnicities and high deprivation were associated with significantly reduced odds of receiving AVR in England,” the authors wrote.
Dr Clare Appleby, a consultant cardiologist at the Liverpool Heart and Chest hospital NHS foundation trust and an author of the study, said public health initiatives to understand and tackle these inequalities should be prioritised.
“Severe symptomatic aortic stenosis is a serious disease that causes mortality and reduces quality of life for patients,” she said. “Left untreated it has a worse prognosis than many common metastatic cancers, with average survival being 50% at two years, and around 20% at five years.”
Until now, not much was known about how inclusive AVR provision is across the NHS in England. To find out, the researchers analysed data from hospital episode statistics from April 2016 to the end of March 2019.
During this time, 183,591 adults with aortic stenosis were identified, 31,436 of whom underwent AVR.
Women with aortic stenosis were 30% less likely to undergo AVR than men, while black and south Asian people were, respectively, 26% and 22% less likely to do so than white people, the study found.
Similarly, people from the most deprived areas were 24% less likely to undergo the procedure than those in the least deprived.
The researchers then linked this data with general practice medical records in the nationally representative clinical practice research database (CPRD) to see who received timely AVR.
While there were no obvious differences by gender, there were racial and socioeconomic differences.
Timely AVR occurred in about two-thirds (65%) of white patients compared with just over half (55%) of black and south Asian patients. And about two-thirds (68%) of those from the least deprived areas had a timely procedure compared with 58% of the most deprived.
Delayed AVR occurred in a higher proportion of black (32%) or south Asian (36%) people than white people (28%), and in a third of those living in areas of greatest deprivation compared with about one in four (26%) of those from areas of least deprivation.
This was an observational study and as such cannot establish cause, nor was it designed to identify barriers to access or provision of care, the researchers said.
“Further research is needed to investigate the reasons for underprovision of AVR in certain person groups and to identify whether disparity is related to structural or systemic inequities, genetic inequalities, or differences in patient behaviours or preferences,” they said.
Appleby added: “Similar evidence is emerging from the US and Europe but to our knowledge this is the first time it has been demonstrated in the UK.” The study did not examine the causes, she said, but they were “likely to be multifactorial”.
Dr Habib Naqvi, the chief executive of the NHS Race and Health Observatory, said: “Given the higher prevalence rates of cardiovascular disease amongst black and Asian people in the UK, it is deeply concerning that the provision of life-saving interventions such as aortic valve replacement is not equitable.
“As the work of the observatory has consistently shown, this is not a unique example of racial disparity in healthcare access. Urgent action is needed to remove the inherent biases that exist in policies, processes and practices across the healthcare system to ensure a recipient of life-saving interventions is not dependent on skin colour or where you live.”
An NHS spokesperson said: “The NHS remains committed to improving timely access to care for patients with severe symptomatic aortic stenosis. While aortic valve replacement is a major operation which won’t be suitable for everyone, it is clear that more needs to be done to fully understand the potential barriers to receiving this procedure and ensure equitable access for all.”
