Advanced pulmonary embolism thrombolysis ‘underused,’ prone to inequitable use

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Key takeaways:

  • Advanced thrombolysis is used in less than 1% of patients presenting with pulmonary embolism.
  • Its use was disparate among women and Black patients, while outcomes varied by sex and race.

Use of advanced thrombolysis in the U.S. remains low and is prone to disparate use among women and Black patients presenting with pulmonary embolism, a speaker reported.

A “big data” analysis of disparities in use of advanced therapy for PE — defined as advanced ultrasound-assisted catheter-directed thrombolysis — was presented at the Society for Cardiovascular Angiography and Interventions Scientific Sessions.

Peter Monteleone

At TCT 2023, Peter Monteleone, MD, interventional cardiologist at the University of Texas at Austin Dell School of Medicine, Ascension Texas Cardiovascular in Austin, presented the results of the REAL-PE trial, which used data from Truveta, a data and analytics company that provides EHR data, to evaluate real-world use and outcomes in catheter-directed thrombolysis for PE.

As Healio previously reported, catheter-directed thrombolysis was associated with reduced risk for major bleeding compared with mechanical thrombectomy for PE.

Sahil Parikh

“PE intervention is one of the fastest-growing procedural fields … There is an absence of class I evidence for procedural performance and there are no mandated registries or clear centers of excellence. And so real-word data is an approach to understand disparities in care,” Sahil Parikh, MD, FACC, FSCAI, associate professor of medicine and director of endovascular services at the Columbia University Vagelos College of Physicians and Surgeons, said during a press conference. “We asked the question, if we could better understand how many patients who were eligible were receiving advanced therapies and if there were any disparities based on gender or ethnicity.”

For this analysis, Monteleone, Parikh and colleagues used data from the Truveta data platform of aggregated EHR data of more than 104 million patients, including diagnosis, device use, procedures, encounter information and lab results. The researchers evaluated use of advanced therapy for PE in subgroups of men compared with women and Black patients compared with white patients.

Parikh noted a limitation was that only patients who underwent advanced therapy with Inari (FlowTriever) and Boston Scientific (EKOS) devices were included.

From Jan. 1, 2018, to May 5, 2023, at total of 435,296 patients were diagnosed with PE, of which 0.48% were treated with advanced therapy.

In the overall cohort of patient who received advanced therapy for PE, 78% were white and 13% were Black. Among white patients, 63% were older than 60 years and 44% were women. Among Black patients, 45% were older than 60 years and 56% were women.

Among all patients with PE, use of advanced therapy was significantly lower among Black patients compared with non-Black patients (0.37% vs. 0.5%; P < .0001) and among women compared with men (0.41% vs. 0.55%; P < .0001).

Among men, the likelihood of International Society on Thrombosis and Hemostasis major bleeding (OR = 0.66; 95% CI, 0.523-0.832; P = .003) and hemoglobin loss of more than 2 mg/dL (OR = 0.781; 95% CI, 0.665-0.917; P = .011) was significantly lower compared with women.

Among white patients, the likelihood of ISTH major bleeding (OR = 1.672; 95% CI, 1.138-2.457; P = .028), hemoglobin loss of more than 2 mg/dL (OR = 1.352; 95% CI, 1.075-1.701; P = .031) or loss of more than 5 mg/dL (OR = 1.539; 95% CI, 1.097-2.159; P = .036) was significantly higher compared with Black patients.

Risk for in-hospital mortality and ischemic stroke was not significantly different between subgroups.

“Advanced PE therapy is both vulnerable to disparate use and perhaps underuse, and these data allow us to illustrate that despite our enthusiasm for these technologies,” Parikh said during the presentation. “Truveta data allowed us to review care decision made for over 400,000 patients with a diagnosis of PE, which is much longer than any other dataset … We need to do further assessment why these [disparities] exist.

“‘Big data’ analytics provide a means for evaluating care disparities in real clinical practice and gives us an opportunity look a real-time monitoring of clinical decision making,” he said. “Both novel and established therapies can benefit from this kind of evaluation.”

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