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Association Between Hospital SAVR Volume and TAVR Outcomes
Study Questions:
What is the association of hospital surgical aortic valve replacement (SAVR) and combined SAVR and transcatheter aortic valve replacement (TAVR) volumes with patient outcomes of TAVR procedures performed within 1 year, 2 years, and for the entire period after initiation of TAVR programs?
Methods:
The investigators conducted an observational cohort study of 60,538 TAVR procedures performed in 438 hospitals between October 1, 2011, and December 31, 2015, among Medicare beneficiaries. The associations between SAVR volume; SAVR and TAVR volumes; and risks of death, death or stroke, and readmissions within 30 days were determined using a hierarchical logistic regression model adjusting for patient and hospital characteristics. The association between SAVR and SAVR and TAVR volumes and 1- and 2-year mortality after TAVR procedures was determined using a multivariable proportional hazard model with a robust variance estimator. The associations for procedures performed within 1 year, 2 years, and for the entire period after initiation of TAVR programs were examined.
Results:
Among the 60,538 patients, 29,173 were women and 31,365 were men, with a mean (standard deviation) age of 82.3 (8.0) years. Hospitals with high SAVR volume (mean annual volume, ≥97 per year) were more likely to adopt TAVR early and had a higher growth in TAVR volumes over time (median TAVR volume by hospitals with high SAVR volume and low SAVR volume: year 1, 32 vs. 19; year 2, 48 vs. 28; year 3, 82 vs. 38; year 4, 118 vs. 54; p < 0.001). In adjusted analysis, high hospital SAVR volume alone was not associated with better patient outcomes after TAVR. When hospital TAVR and SAVR volumes were jointly analyzed, patients treated in hospitals with high TAVR volume had lower 30-day mortality after TAVR (high TAVR and low SAVR vs. low TAVR and low SAVR: odds ratio, 0.85; 95% confidence interval [CI], 0.72-0.99; high TAVR and high SAVR vs. low TAVR and high SAVR: odds ratio, 0.81; 95% CI, 0.69-0.95), the effect of which was more pronounced when hospitals also had high SAVR volume. Patients treated in hospitals with high SAVR volume and high TAVR volume had the lowest 30-day mortality (vs. hospitals with low SAVR volume and TAVR volume: odds ratio, 0.77; 95% CI, 0.66-0.89).
Conclusions:
The authors concluded that hospitals with high caseloads of both SAVR and TAVR are likely to achieve the best outcomes.
Perspective:
This study reports that hospitals with high SAVR volume were more likely to adopt TAVR early and had faster growth in TAVR volume. However, hospital SAVR volume alone was not associated with better postoperative outcomes and 1- and 2-year mortality after TAVR. Of note, patients undergoing TAVR at hospitals with high SAVR volume and high TAVR volume had the lowest 30-day, 1-year, and 2-year mortality. Policy decisions to determine the need of volume requirement need to factor in the likelihood of hospitals with higher SAVR volume to more frequently perform TAVR and the combined benefit of hospitals’ surgical and accumulated TAVR experience for patients undergoing TAVR instead of focusing only on surgical volume.
Clinical Topics: Cardiac Surgery, Geriatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Prevention, Valvular Heart Disease, Cardiac Surgery and Arrhythmias, Cardiac Surgery and VHD, Interventions and Structural Heart Disease
Keywords: Cardiac Surgical Procedures, Geriatrics, Heart Valve Diseases, Heart Valve Prosthesis, Medicare, Outcome Assessment, Health Care, Patient Readmission, Secondary Prevention, Transcatheter Aortic Valve Replacement
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