Socioeconomic Disparities in Surveillance and Follow-Up of Patients with
Thoracic Aortic Aneurysm
Abstract
Background: Thoracic aortic aneurysm is a significant risk factor for
aortic dissection and rupture. Guidelines recommend referral of patients
to a cardiovascular specialist for periodic surveillance imaging with
surgical intervention determined primarily by aneurysm size. We
investigated the association between socioeconomic status and
surveillance practices in patients with ascending aortic aneurysms.
Methods: We retrospectively reviewed records of 465 consecutive patients
diagnosed between 2013-2016 with ascending aortic aneurysm ≥4cm on
computed tomography scans. Primary outcomes were clinical follow-up with
a cardiovascular specialist and aortic surveillance imaging within 2
years following index scan. We stratified patients into quartiles using
the area deprivation index (ADI), a validated percentile measure of 17
variables characterizing socioeconomic status at the census block group
level. Competing risks analysis was used to determine interquartile
differences in risk of death prior to follow up with a cardiovascular
specialist. Results: Lower socioeconomic status was associated with
significantly lower rates of surveillance imaging and referral to a
cardiovascular specialist. On competing risks regression, the ADI
quartile with lowest socioeconomic status had lower hazard of follow-up
with a cardiologist or cardiac surgeon prior to death (HR 0.46 [0.34,
0.62], p<0.001). Though there were no differences in
aneurysm size at time of surgical repair, patients in the lowest
socioeconomic quartile were more frequently symptomatic at surgery than
other quartiles (92% vs 23-38%, p<0.001). Conclusion:
Patients with lower socioeconomic status receive less timely follow-up
imaging and specialist referral for thoracic aortic aneurysms, resulting
in surgical intervention only when alarming symptoms are already
present.