Interactions Between Health Inequalities on the Management and Outcomes of Thoracic Aortic Disease in England: A National Cohort Study

BACKGROUND: The aim of this study was to evaluate the intersectionality between measured causes of health inequality and clinical factors that influence treatment decisions and regional variations in care and survival for people with thoracic aortic disease (TAD) in England. METHODS: The target population was all new TAD diagnoses in English hospitals between April 2013 and March 2018 with at least a 1-year follow-up. Adjusted regression models analyzed the associations between age, sex, race and ethnicity, socioeconomic deprivation, and geographic region with 1-year all-cause death, early elective thoracic aortic intervention, and referral for imaging surveillance or clinical genetics screening. RESULTS: The analysis cohort included 33 793 new TAD diagnoses with complete baseline and follow-up data. In multivariate analyses, older patients, women, and people from economically deprived areas, were more likely to die within 1 year of diagnosis. Exploratory analyses showed that older people, people of Asian or Black race, and those from deprived areas were less likely to undergo early treatment, and older people, women, and people from deprived areas were more likely to undergo surveillance scans within 6 months of diagnosis. People from areas of deprivation were less likely to be referred for genetic screening. After adjustment for baseline differences and health inequalities, there was significant regional variation in the proportion of people with newly diagnosed TAD who underwent treatment and aortic surveillance. CONCLUSIONS: There are multilevel sources of inequality in access to care and survival following a diagnosis with TAD in England. These findings expose a significant evidence-to-practice gap and the need for national strategies to implement equitable standardized care pathways.