Automated Referral Prompts Reveal Lack of Equitable Access to Care in Patients With Aortic Stenosis

Despite the high prevalence and significant mortality associated with aortic stenosis (AS), data demonstrate low rates of referral to specialized heart valve teams. The objectives of this study were therefore to highlight contemporary referral patterns in patients with significant AS and identify potential barriers to referral.

Patients undergoing transthoracic echocardiography (TTE) in a large public health catchment had automatically generated text inserted into their TTE report and electronic medical record if the TTE met the American Society of Echocardiography criteria for moderate or severe AS. Text recommended referral to a heart valve team for further assessment or treatment. Patients were prospectively identified and followed. Structured telehealth was performed to clarify symptom status and perceived barriers to referral.

Over 6 months, 343 patients with severe (n = 142) or moderate (n = 201) AS were identified. Despite significant AS alongside a referral prompt, only 86 (61%) patients with severe and 44 (22%) with moderate AS were referred for assessment. Patient and echocardiographic characteristics were similar between referred and nonreferred. Mortality was significantly higher in nonreferred patients with severe AS (19.6 vs. 2.3% referred, p < 0.001). Of the nonreferred patients who died, 5/11 (45%) had no compelling reason for lack of referral. Most nonreferred patients with severe AS reported progressive symptoms (75% New York Heart Association class II/III). Over half (51.2%) reported being managed with a "watchful waiting" strategy despite meeting a class I indication for aortic valve replacement, and nearly one-third (27.5%) were unaware of their diagnosis.

Despite automatically generated referral prompts in patients with severe AS, many patients without a compelling reason for lack of referral were not appropriately assessed and died.