Relationship between patient income level and mitral valve repair utilization

Abstract

Background: The superiority of mitral valve (MV) repair is well established with respect to long-term survival, preservation of ventricular function, and valve-related complications. The relationship between patient income level and the selection of MV procedure (repair versus replacement) has not been studied.

Methods: The 2005 to 2007 Nationwide Inpatient Sample database was searched for patients ≥ 30 years old with MV repair or replacement; patients with ischemic and congenital MV disease were excluded. Patients were stratified into quartiles according to income level (quartile 1, lowest; quartile 4, highest). We used univariate and multivariate models to compare patients with respect to baseline characteristics, selection of MV procedure, and hospital mortality.

Results: The preoperative profiles of the income quartiles differed significantly, with more risk factors occurring in the lower income quartiles. Unadjusted hospital mortality decreased with increasing income quartile. The percentage of patients receiving MV repair increased with increasing income (35.6%, 39.6%, 48.2%, and 55.8% for quartiles 1, 2, 3, and 4, respectively; P = .0001). Following adjustment for age, race, sex, urban residency, admission status, primary payer, Charlson comorbidity index, and hospital location and teaching status, the income quartiles had similar hospital death rates, whereas the highly significant relationship between valve repair and income level persisted (P = .0008).

Conclusions: Significant disparity exists among patients in the different income quartiles with respect to the likelihood of receiving MV repair. MV repair is performed less frequently in patients with lower incomes, even after adjustment for differences in baseline characteristics. The higher unadjusted mortality rate for less affluent patients appears mostly related to their worse preoperative profiles.