Drivers and outcomes of variation in surgical versus transcatheter aortic valve replacement in Ontario, Canada: a population-based study

Abstract

ObjectivesTo understand the patient and hospital level drivers of the variation in surgical versus trascatheter aortic valve replacement (SAVR vs TAVR) for patients with aortic stenosis (AS) and to explore whether this variation translates into differences in clinical outcomes.BackgroundAdoption of TAVR has grown exponentially worldwide. Notwithstanding, a wide variation in TAVR rates has been seen within and between countries and in some jurisdictions AS is still primarily being managed by SAVR.MethodsWe conducted a population-based retrospective cohort study in Ontario, Canada, including individuals who received TAVR or SAVR between 2016 and 2020. We developed iterative hierarchical logistic regression models for the likelihood of receiving TAVR instead of SAVR examining sequentially patient characteristics, hospital factors and year of procedure, calculating the median ORs and variance partition coefficients for each. Using Cox proportional hazards models, we examined the relationship between TAVR/SAVR ratio on all-cause mortality and readmissions.ResultsAnnual procedures rates per million population increased from 171 to 201, mainly driven by the expansion of TAVR. TAVR/SAVR ratios differed substantially between hospitals, from 0.21 to 3.27. Neither patient nor hospital factors explained the between-hospital variation in AS treatment. The TAVR/SAVR ratio was significantly associated with clinical outcomes with high ratio hospitals having lower mortality and rehospitalisations.ConclusionsDespite the expansion of TAVR, dramatic variation exists that is not explained by patient or hospital factors. This variation was associated with differences in clinical outcomes, suggesting that further work is needed in understanding and addressing inequity of access.

Burden of cardiovascular disease in a large contemporary cohort of patients with heterozygous familial hypercholesterolemia

“…Lastly, the incidence of aortic valve replacement was particularly high in patients with HeFH at 1.78 per 1000 PY. In the province of Ontario, Canada, aortic valve replacement was 0.20 per 1000 PY [ 20 ], markedly lower than in our study. In Norway, a cohort of 3161 patients with genetically verified HeFH were followed for 11.1 years [ 21 ].…”

Transcatheter Aortic Valve Implantation Wait‐Time Management: Derivation and Validation of the Canadian TAVI Triage Tool (CAN3T)

“…1 As a result, the demand for TAVI has grown exponentially worldwide, outpacing capacity in many jurisdictions, resulting in substantial wait times. 2 , 3 For example, in Ontario, Canada, despite a 5‐fold improvement in the penetration of TAVI in the health system, 2 , 4 median wait times worsened from 80 days in 2012 to 110 days in 2018. 5 …”

Impact of Neighborhood Social Deprivation on Delays to Access for Transcatheter Aortic Valve Replacement: Wait‐Times and Clinical Consequences

“… 10 Importantly, it has been established that even among more developed nations, access to TAVR is not uniform, 11 with substantial geographic inequity. 12 , 13 The implications of marginalization on this inequitable distribution have yet to be thoroughly explored.…”