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Surgical AVR Trends According to TAVR Volumes
Study Questions:
Is there a relationship between hospital transcatheter aortic valve replacement (TAVR) volume and patient characteristics, volumes, and outcomes for isolated surgical AVR (SAVR)?
Methods:
Hospitalizations of adults (≥18 years) with International Classification of Diseases, 9th Revision, Clinical Modification procedure codes for SAVR (35.21 or 35.22) or TAVR (35.05 or 35.06) who were included in the Medicare Provider Analysis and Review database from 2011 through 2014 were identified and analyzed. Trends in isolated SAVR patient characteristics, procedural volumes, and outcomes by quartile (Q) of hospital-level TAVR use were assessed over the study period.
Results:
A total of 37,705 isolated SAVR procedures were analyzed for the study. The annual volume of isolated SAVR procedures decreased in hospitals performing the largest number of TAVR procedures (Q3: 1,557 in 2011 to 1,391 in 2014; and Q4: 2,607 in 2011 to 1,791 in 2014). Thirty-day and 1-year mortality after SAVR also declined over the study period in hospitals with the largest TAVR volume (annual change rate in mortality for Q3: -16.4%, p < 0.001; Q4: - 20.8%, p < 0.001).
Conclusions:
The advent of TAVR was associated with a reduction in isolated SAVR volumes, a decrease in comorbidities among patients undergoing SAVR, and corresponding reductions in observed short- and long-term SAVR mortality among hospitals performing the greatest number of TAVRs.
Perspective:
Since its approval, TAVR volume has increased in the United States, and now exceeds that of isolated SAVR. Although previous studies from the US and Europe suggested that SAVR volume is not affected by TAVR volume, this study demonstrates that the volume of isolated SAVR declined between 2011 and 2014 in hospitals performing the highest volume of TAVR. Accompanying reductions in comorbidities and postoperative mortality associated with SAVR suggest that high-volume TAVR centers tended to perform isolated SAVR among less complicated patients. As TAVR use continues to expand, SAVR volume may continue to decline; it remains to be seen whether declining surgical volumes might in the future adversely affect SAVR outcomes.
Keywords: Aortic Valve, Cardiac Surgical Procedures, Comorbidity, Heart Valve Diseases, Heart Valve Prosthesis, Hospitals, High-Volume, Hospitals, Low-Volume, International Classification of Diseases, Medicaid, Outcome Assessment, Health Care, Transcatheter Aortic Valve Replacement
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