There may be significant hospital-level variations in pediatric balloon aortic valvuloplasty (BAV) and balloon pulmonary valvuloplasty (BPV) that cannot be explained by patient- and procedure-level characteristics, according to research published March 19 in JACC: Cardiovascular Interventions.

Andrew C. Glatz, MD, et al., studied BAV and BPV procedures recorded in ACC's IMPACT Registry between January 2011 and September 2015. Researchers collected data on demographics, pre-catheterization clinical history, indication for the procedure, hemodynamics and specific case details for 1,071 BAV cases at 60 hospitals and 2,207 BPV cases at 75 hospitals.

In addition, researchers collected information about the hospitals, including center volume, percentage of procedures performed in patients older than 18, teaching status, census region, hospital type, and hospital setting. Hospital-level variation was measured using the distribution of indications for the procedure and consistency with published guidelines in cases with high-resting gradient as the indication.

For both BAV and BPV, the indication was high-resting gradient for 82 percent of the procedures. In BAV cases, 86 percent were performed in a manner consistent with published guidelines, compared with 66 percent of BPV cases. Researchers noted significant hospital-level variation in the rates of procedures that were consistent with published guidelines. For example, 63 percent of hospitals performed more than 80 percent of BAV cases consistently with guidelines, compared with 30 percent of hospitals that performed BPV consistently with guidelines in more than 80 percent of cases. Overall, 11.9 percent of BAV cases were inconsistent with guidelines, compared with 34.8 percent of BPV cases. For BAV, there were significant differences across census regions, with hospitals in the Eastern and Southern U.S. more likely to follow guidelines consistently. For BPV, there was no association between hospital factors and rates of consistent practice, but there were significant inter-hospital variations.

According to the researchers, further investigation is necessary to demonstrate that the variations affect quality of care and that a decrease in variations could lead to quality improvement.

In an accompanying editorial, Thomas K. Jones, MD, FACC, asks whether gradient thresholds that were "established in the surgical treatment era decades ago" are the "appropriate yardstick with which to inform treatment guidelines in the current less invasive percutaneous treatment era." In addition, Jones writes that while the existence of variations is "beyond dispute," determining whether the variations "constitute evidence of gaps in quality of care is another thing," adding that long-term follow-up is required to "accurately make the connection between practice variation and quality of care."

Keywords: Quality Improvement, Balloon Valvuloplasty, Registries, IMPACT Registry, National Cardiovascular Data Registries

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