Procedural Volume and Outcomes for Transcatheter Aortic-Valve Replacement. - 2019

Available online from MWHC library: 1993 - present, Available in print through MWHC library: 1980 - present

BACKGROUND: During the introduction of transcatheter aortic-valve replacement (TAVR) in the United States, requirements regarding procedural volume were mandated by the Centers for Medicare and Medicaid Services as a condition of reimbursement. A better understanding of the relationship between hospital volume of TAVR procedures and patient outcomes could inform policy decisions. CONCLUSIONS: An inverse volume-mortality association was observed for transfemoral TAVR procedures from 2015 through 2017. Mortality at 30 days was higher and more variable at hospitals with a low procedural volume than at hospitals with a high procedural volume. (Funded by the American College of Cardiology Foundation National Cardiovascular Data Registry and the Society of Thoracic Surgeons.). Copyright (c) 2019 Massachusetts Medical Society. METHODS: We analyzed data from the Transcatheter Valve Therapy Registry regarding procedural volumes and outcomes from 2015 through 2017. The primary analyses examined the association between hospital procedural volume as a continuous variable and risk-adjusted mortality at 30 days after transfemoral TAVR. Secondary analysis included risk-adjusted mortality according to quartile of hospital procedural volume. A sensitivity analysis was performed after exclusion of the first 12 months of transfemoral TAVR procedures at each hospital. RESULTS: Of 113,662 TAVR procedures performed at 555 hospitals by 2960 operators, 96,256 (84.7%) involved a transfemoral approach. There was a significant inverse association between annualized volume of transfemoral TAVR procedures and mortality. Adjusted 30-day mortality was higher and more variable at hospitals in the lowest-volume quartile (3.19%; 95% confidence interval [CI], 2.78 to 3.67) than at hospitals in the highest-volume quartile (2.66%; 95% CI, 2.48 to 2.85) (odds ratio, 1.21; P = 0.02). The difference in adjusted mortality between a mean annualized volume of 27 procedures in the lowest-volume quartile and 143 procedures in the highest-volume quartile was a relative reduction of 19.45% (95% CI, 8.63 to 30.26). After the exclusion of the first 12 months of TAVR procedures at each hospital, 30-day mortality remained higher in the lowest-volume quartile than in the highest-volume quartile (3.10% vs. 2.61%; odds ratio, 1.19; 95% CI, 1.01 to 1.40).


English

0028-4793

10.1056/NEJMsa1901109 [doi]


*Aortic Valve Stenosis/su [Surgery]
*Hospitals, High-Volume/sn [Statistics & Numerical Data]
*Hospitals, Low-Volume/sn [Statistics & Numerical Data]
*Transcatheter Aortic Valve Replacement/mo [Mortality]
Aged
Aged, 80 and over
Aortic Valve/su [Surgery]
Centers for Medicare and Medicaid Services (U.S.)
Female
Hospital Mortality
Humans
Insurance, Health, Reimbursement/st [Standards]
Male
Retrospective Studies
Transcatheter Aortic Valve Replacement/mt [Methods]
Transcatheter Aortic Valve Replacement/sn [Statistics & Numerical Data]
Treatment Outcome
United States/ep [Epidemiology]


MedStar Heart & Vascular Institute


Journal Article
Research Support, Non-U.S. Gov't