Journal Wrap | NCDR Studies Probe Racial Disparities; TAVR Effectiveness

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The hottest research from various peer-reviewed journals – handpicked weekly by the Editorial Board led by Kim Eagle, MD, MACC.

NCDR Study: No Change in Racial Disparities in MI Outcomes Following HRRP Implementation

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Racial disparities in 30-day readmission and mortality rates among Medicare beneficiaries hospitalized with myocardial infarction (MI) did not change following implementation of the Centers for Medicare and Medicaid Services (CMS) Hospital Readmissions Reduction Program (HRRP), according to a study published in JAMA Cardiology.

Ambarish Pandey, MD, MSCS, et al., used data from ACC's Chest Pain – MI Registry to assess trends in 30-day readmission and mortality rates among black and nonblack patients hospitalized for MI from 2008 through 2016. The researchers used CMS claims data to determine 30-day all-cause readmission and mortality rates and stratified results by hospital performance category, defined as low vs. high performing based on HRRP readmission penalty status.

The final study cohort comprised 155,397 patients with MI treated at 753 hospitals. Of all patients, 11,280 (7.3 percent) were black. Of the 753 hospitals, 399 (53 percent) were categorized as high performing. During the study period, there was a steady decline in 30-day readmission rates among both black (20.8 percent in 2009 vs. 17.4 percent in 2016) and nonblack patients (17.9 percent vs. 14.5 percent). Black patients had higher unadjusted odds of 30-day readmission in both low- and high-performing hospitals, however these differences were attributable to clinical characteristics and disease severity.

During the study period, there were significant declines in 30-day mortality among nonblack patients in both low- and high-performing hospitals, while 30-day mortality remained stable among black patients. Among black patients, mortality declined in low-performing hospitals but not in high-performing hospitals, with no significant changes based on HRRP implementation.

According to the researchers, the study's findings may "potentially allay concerns that penalizing low-performing hospitals with reduced CMS payments under HRRP has led to worsening racial disparities in clinical outcomes." They conclude that HRRP implementation "has not been associated with worsening or improvement in these racial differences in 30-day outcomes."

In an accompanying editorial comment, Martha J. Radford, MD, FACC, writes that the study "sheds light on possible reasons for the unwavering racial disparity in readmission rates," noting that black patients have higher prevalence of diabetes, hypertension, heart failure and other clinical risk factors. Moving forward, she suggests an "adjustment of therapeutic decisions to reflect individual patient needs, including (for some patients) the need for readmission."

Pandey A, Keshvani N, Khera R, et al. JAMA Cardiol 2020;Jan 8:[Published online before print].

TAVR May Be Effective For AR When SAVR Not an Option: NCDR Study

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Transcatheter aortic valve replacement (TAVR) may be appropriate in patients with aortic regurgitation (AR) who are not candidates for surgical aortic valve replacement, according to a study published recently in the American Journal of Cardiology.

Using data from the STS/ACC TVT Registry, Saif Anwaruddin, MD, et al., evaluated outcomes in 230 patients who underwent TAVR for native AR using a commercially available self-expanding valve system.

The study's primary outcome was 30-day all-cause mortality, while secondary outcomes included in-hospital clinical outcomes, postprocedure AR rates, device success and one-year all-cause mortality.

According to the results, the 30-day all-cause mortality rate was 13.3 percent. In-hospital all-cause mortality occurred in 12.2 percent of patients, and the median length of stay in hospital was 5.5 days.

After TAVR, about 10 percent of patients had moderate to severe AR. Overall, device success was reported in 81.7 percent of patients. The success rate improved among patients who underwent TAVR with newer vs. older generation devices. The one-year all-cause mortality rate was 22.8 percent.

The study's findings suggest that, despite high 30-day all-cause mortality, self-expanding TAVR may be effective in reducing AR and improving quality of life in patients who are not suitable candidates for surgery, the authors note. They conclude that improved outcomes in patients who received newer generation devices "highlight the need for advancements in device technology and careful patient selection."

Anwaruddin S, Desai ND, Szeto WY, et al. Am J Cardiol 2019;124:781-8.

Clinical Topics: Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Prevention, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Acute Heart Failure, Interventions and Structural Heart Disease, Hypertension

Keywords: ACC Publications, Cardiology Magazine, Patient Readmission, Transcatheter Aortic Valve Replacement, Medicare, Centers for Medicare and Medicaid Services, U.S., Risk Factors, Aortic Valve Insufficiency, Aortic Valve, Patient Selection, Quality of Life, Length of Stay, Hospital Mortality, Medicaid, Hospitals, Registries, Prevalence, Myocardial Infarction, Chest Pain, Diabetes Mellitus, Hypertension, Cohort Studies, Heart Failure

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