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Utility of 30- vs. 90-Day Mortality Quality Metrics for AVR Outcomes
Study Questions:
What is the utility of 30-day versus 90-day mortality after transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) as a mortality quality metric?
Methods:
The investigators analyzed data from Medicare beneficiaries undergoing TAVR and SAVR procedures from January 1, 2012, to December 31, 2015. Concomitant coronary artery bypass grafting and other heart valve or other major open-heart procedures were excluded. Hospitals that performed fewer than 50 TAVR or 70 SAVR procedures per year were excluded to ensure reliable estimates and to reduce the risks of inflated results because of small institutional sample sizes. Data were analyzed from October 2018 to August 2019. Hospitals were ranked into top- (10%), middle- (80%), and bottom-performing (10%) groups based on their 4-year mean 30-day mortality. The main outcome measures were changes in hospital performance rankings at 90 days and 1 year, and correlation of 30- and 90-day mortality with 1-year mortality was also examined.
Results:
A total of 30,329 TAVR admissions at 184 hospitals and 26,021 SAVR admissions at 191 hospitals were evaluated. For TAVR, 40 hospitals (21.7%) changed performance rankings at 90 days: 13 (48.1%) in the top-performing group and eight (29.6%) in the bottom-performing group. At 1 year, 56 hospitals (30.4%), which included 21 (77.8%) in the top-performing group and 12 (44.4%) in the bottom-performing group, changed rankings. Similar findings were observed for SAVR, with an overall 90-day conversion rate of 17.3% and a 1-year rate of 30.3%. These findings persisted after adjusting for the differences in patient risk profiles among the three groups. Capturing 90-day events was also more robustly informative regarding expected 1-year outcomes after both TAVR and SAVR, largely owing to the observed plateau in the instantaneous hazard observed beyond this point.
Conclusions:
The authors concluded that evaluation of hospital performance based on 30-day mortality may underestimate outcomes and therefore substantially misrepresent institutional performance after TAVR and SAVR compared with 90-day mortality.
Perspective:
This study reports a persistent risk of mortality after TAVR and SAVR that remained elevated through 90 days, but then plateaued to fairly constant levels in the first year after the procedure. Furthermore, the 30-day mortality outcome metric underestimated procedure-related outcomes and therefore substantially misrepresented institutional performance after TAVR and SAVR compared with 90 days, even after risk adjustment. Overall, these findings emphasize the need to re-examine the utility of 90-day mortality as a potentially valuable additional performance metric for TAVR and SAVR with emphasis on quality control.
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, Cardiology Interventions, Geriatrics, Heart Valve Diseases, Heart Valve Prosthesis, Outcome Assessment, Health Care, Quality Control, Risk Adjustment, Secondary Prevention, Transcatheter Aortic Valve Replacement
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