PAH in Hispanic Patients: Outcomes and Social Determinants of Health

An analysis of clinical trial data found that Hispanic patients with pulmonary arterial hypertension (PAH) were younger and had more ED visits and hospitalizations than non-Hispanic White patients, but that Hispanic ethnicity was not associated with differences in survival. These were among study findings published in Annals of the American Thoracic Society.

A 2017 Statement by the American Thoracic Society noted that “minorities with PAH may be at risk for worse outcomes due to difficulty accessing healthcare, lack of or limited insurance, poor socioeconomic status, and distrust of the healthcare system, among other factors.” In light of this, as well as the notable underrepresentation of patients of racial/ethnic minorities in PAH clinical trials and registries, the investigators in the current study sought to describe the clinical and sociodemographic profile of Hispanic patients with PAH, taking into account social determinants of health.

In this prospective cohort study, the investigators analyzed data derived from the Pulmonary Arterial Hypertension Registry (PHAR; ClinicalTrials.gov Identifier: NCT04071327) — a multicenter, US-based registry of patients who are treated at Pulmonary Hypertension Care Centers. Based on self-reported ethnicity, the participants were classified as Hispanic or non-Hispanic White. Baseline clinical and sociodemographic characteristics between the groups were compared with the use of absolute standardized differences (ASDs).

The primary study outcome was an assessment of transplant-free survival among Hispanics compared with non-Hispanic Whites. Following adjustments for age, sex, annual income, education level, type of  health insurance, and PAH etiology, a Cox proportional hazards model was used for the multivariable analysis.

A total of 683 participants were enrolled in the study, with 14.3% (98 of 683) of them of Hispanic ethnicity. Results of the study showed that Hispanic patients, compared with non-Hispanic White patients, had impaired access to health care (31.6% vs 12.9%, respectively, among Medicaid/uninsured; ASD, 0.35), lower level of education (72.6% vs 94.0%, respectively, among high school graduates or higher; ASD, 0.60), and lower annual income (32.0% vs 17.4%, respectively, among those with incomes of <20,000 US dollars; ASD, 0.47).

Further, Hispanic participants had a higher rate of emergency department visits and a higher number of hospitalizations than non-Hispanic White participants, despite exhibiting similar disease severity (incidence rate ratio [IRR], 1.452; 95% CI, 1.326-1.590 vs IRR, 1.428; 95% CI, 1.292-1.577, respectively).

Although the unadjusted analysis revealed a lower transplant/death hazard ratio (HR) for Hispanics (HR, 0.47; 95% CI, 0.24-0.94; P =.032), no association was observed between Hispanic ethnicity and outcome in the multivariable model, after adjustments for SDOH and other covariates (HR, 0.76; 95% CI, 0.35-1.62; P =.474).

“[W]e did not find a difference in survival in Hispanic patients with PAH. However, we did find that Hispanic patients had a higher frequency of ER visits and a higher number of hospitalizations, despite a similar severity of illness, suggesting that disease control was less optimal in Hispanics, which could be explained by a disadvantageous SDOH profile,” said study authors.

The researchers also noted that Hispanic patients were of younger age, which is associated with improved outcomes, and that their findings suggested that age was an important driver of the differences in survival. “Similarly, a higher proportion of [congenital heart disease-associated pulmonary arterial hypertension] in Hispanic patients could also be associated with longer survival,” the investigators added.

Limitations of the study include its relatively small sample size. Additionally, the data from the current analysis represented health care outcomes among patients who were treated at tertiary centers with major expertise in PAH, thus limiting the generalizability of the findings.

Reference  

Bernardo RJ, Lu D, Ramirez RL III, et al; PHAR Study Group. Hispanic ethnicity and social determinants of health in pulmonary arterial hypertension: the Pulmonary Hypertension Association Registry. Ann Am Thorac Soc. Published online March 3, 2022. doi:10.1513/AnnalsATS.202109-1051OC