Safety‐net hospitals versus non‐safety centers and clinical outcomes after trans‐catheter aortic valve replacement

Abstract

Objective To compare post‐procedural outcomes of trans‐catheter valve replacement (TAVR) among safety‐net (SNH) and non‐safety net hospitals (non‐SNH). Background SNH treat a large population of un‐insured and low income patients; prior studies report worse outcome at these centers. Results of TAVR at these centers is limited. Methods Adults undergoing TAVR at hospitals in the US participating in the National In‐patient sample (NIS) database from January 2014 to December 2015 were included. A 1:1 propensity‐matched cohort of patients operated at SNH and non‐SNH institutions was analyzed, on the basis of 16 demographic and clinical co‐variates. Main outcome was all‐cause post‐procedural mortality. Secondary outcomes included stroke, acute kidney injury and length of post‐operative stay. Results Between 2014 and 2015, 41,410 patients (mean age 80 ± 0.11 years, 46% female) underwent TAVR at 731 centers; 6,996 (16.80%) procedures were performed at SNH comprising 135/731 (18.4%) of all centers performing TAVR. SNH patients were more likely to be female (49% vs. 46%, p < .001); admitted emergently (31% vs. 21%; p < .001; at the lowest quartile for household income (25% % vs. 20%; p < .001) and from minorities (Blacks 5.9% vs. 3.9%; Hispanic 7.2% vs. 3.2%).Adjusted logistic regression was performed on 6,995 propensity‐matched patient pairs. Post‐procedural mortality [OR 0.99(0.98–1.007); p = .43], stroke [OR 1.009(0.99–1.02); p = .08], acute kidney injury [OR 0.99(0.96–1.01); p = .5] and overall length of stay (6.9 ± 0.1 vs. 7.1 ± 0.2 days; p = .57) were comparable in both cohorts. Conclusion Post‐procedural outcomes after TAVR at SNH are comparable to national outcomes and wider adoption of TAVR at SNH may not adversely influence outcomes.

Association between hospital racial composition and aortic valve replacement outcomes: A national inpatients sample database analysis

“…mortality rates, unaffected by RDI variations, are similar to prior studies suggesting hospital-centric factors like teaching status or safety-net designation don't significantly skew post-SAVR and post-TAVI mortality. 25,26 However, it's essential to note the elevated unadjusted mortality rates in high RDI hospitals could be attributed to pre-existing comorbidities.…”

Length of Stay in Older Patients Undergoing Transcatheter Aortic Valve Replacement: Value of a Geriatric Approach

“…The primary outcome was the length of hospital stay, defined by the time physically spent in hospitalization until discharge (or in-hospital death). Because in numerous studies the mean LOS is between 5 and 7 days, a prolonged LOS was defined by a LOS strictly longer than 7 days [8, 10, 11, 17].…”

Economic Considerations in Access to Transcatheter Aortic Valve Replacement

“…Thus, not only are many safety-net hospitals financially precluded from offering TAVR but also many patients who receive services at safety-net hospitals thereby forgo the procedure and positive postprocedure outcomes. 41 Large upfront costs for TAVR (eg, $30 000 to $35 000 on average for a TAVR valve and thousands more for cardiac diagnostic, operating room, and rehabilitation therapy costs) ultimately outweigh the cost savings TAVR generates in reduced LOS, so many hospitals are precluded from establishing TAVR programs due to the net negative rate of return and the extended payback period. 6,23 Even a slight decrease in either the fixed or variable costs of TAVR would allow hospitals to more easily reach the caseload required to break even on TAVR procedures.…”