The Relation between Volume and Outcome of Transcatheter and Surgical Aortic Valve Replacement: A Systematic Review and Meta-Analysis

He, Jialing; Zhang, Zhen; Wang, Han; Cai, Lin

doi:10.1155/2020/2601340

Cited by 8 publications

(5 citation statements)

References 33 publications

(34 reference statements)

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“…First, we cannot rule out residual confounding as the cause. Second, this observation may be indicative of lower operator and institutional experience, which has been found to be associated with patient outcomes 27 28. The volume-outcome hypothesis does not explain why higher TAVR/SAVR ratios have improved outcomes even in SAVR patients.…”

Section: Discussionmentioning

confidence: 95%

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

et al. 2022

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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.

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Section: Discussionmentioning

confidence: 95%

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

et al. 2022

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“…There is little information available about the effect of the size or type of hospital on the diagnosis and management of patients with AS. On the one hand, it is well known that high procedural volume translates into better outcomes for both SAVR and TAVI procedure 9–12. On the other hand, there are little data on the centre type and its relation to outcomes.…”

Section: Discussionmentioning

confidence: 99%

Severe aortic stenosis management in heart valve centres compared with primary/secondary care centres

Rudolph

Messika–Zeitoun

Frey

et al. 2023

Heart

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ObjectiveCurrent guidelines recommend use of heart valve centres (HVCs) to deliver optimal quality of care for patients with valve disease but there is no evidence to support this. The hypothesis of this study is that patient care with severe aortic stenosis (AS) will differ in HVCs compared with satellite centres. We aimed to compare the treatment of patients with AS at HVCs (tertiary care hospitals with full access to AS interventions) to satellites (hospitals without such access).MethodsIMPULSE enhancedis a European, observational, prospective registry enrolling consecutive patients with newly diagnosed severe AS at four HVCs and 10 satellites. Clinical characteristics, interventions performed and outcomes up to 1 year by site-type were examined.ResultsAmong 790 patients, 594 were recruited in HVCs and 196 in satellites. At baseline, patients in HVCs had more severe valve disease (higher peak aortic velocity (4.3 vs 4.1 m/s; p=0.008)) and greater comorbidity (coronary artery disease (CAD) (44% vs 27%; p<0.001) prior myocardial infarction (MI) (11% vs 5.1%; p=0.011) and chronic pulmonary disease (17% vs 8.9%; p=0.007)) than those presenting in satellites. An aortic valve replacement was performed more often by month 3 in HVCs than satellites in the overall population (52.6% of vs 31.3%; p<0.001) and in symptomatic patients (66.7% vs 43.2%, p<0.001). One-year survival rate was higher for patients in HVCs than satellites (HR2.19; 95% CI 1.28 to 3.73 total population and 2.89 (95%CI 1.64 to 5.11) for symptomatic patients.ConclusionsOur data support the implementation of referral pathways that direct patients to HVCs performing both surgery and transcatheter interventions.Trial registration numberNCT03112629.

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“…In the present study, even a modeled strict enforcement of a volume threshold as a structural quality measure was not projected to improve population-level TAVI outcomes. TAVI site procedural volume has a demonstrable link to outcomes making it a theoretically appropriate structural indicator of quality . However, structural indicators of quality are surrogates in that they measure the capacity to provide high-quality care and do not actually measure the provision or receipt of quality care.…”

Section: Discussionmentioning

confidence: 99%

“…20 The TVT composite model is a National Quality Forum-endorsed hierarchical proportional odds regression model that was developed for national outcomes benchmarking. 31 The best outcome site in each HRR was defined as the site with the lowest adjusted odds ratio for the composite outcome. Best outcome sites were then grouped and descriptively compared with the remaining sites.…”

Section: Descriptive Analysismentioning

confidence: 99%

Modeling the Association of Volume vs Composite Outcome Thresholds With Outcomes and Access to Transcatheter Aortic Valve Implantation in the US

et al. 2023

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ImportanceProfessional societies and the Centers for Medicare &amp; Medicaid Services suggest volume thresholds to ensure quality in transcatheter aortic valve implantation (TAVI).ObjectiveTo model the association of volume thresholds vs spoke-and-hub implementation of outcome thresholds with TAVI outcomes and geographic access.Design, Setting, and ParticipantsThis cohort study included patients who enrolled in the US Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy registry. Site volume and outcomes were determined from a baseline cohort of adults undergoing TAVI between July 1, 2017, and June 30, 2020.ExposuresWithin each hospital referral region, TAVI sites were categorized by volume (&lt;50 or ≥50 TAVIs per year) and separately by risk-adjusted outcome on the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy 30-day TAVI composite during the baseline period (July 2017 to June 2020). Outcomes of patients undergoing TAVIs from July 1, 2020, to March 31, 2022, were then modeled as though the patients had been treated at (1) the nearest higher volume (≥50 TAVIs per year) or (2) the best outcome site within the hospital referral region.Main Outcomes and MeasuresThe primary outcome was the absolute difference in events between the adjusted observed and modeled 30-day composite of death, stroke, major bleeding, stage III acute kidney injury, and paravalvular leak. Data are presented as the number of events reduced under the above scenarios with 95% bayesian credible intervals (CrIs) and median (IQR) driving distance.ResultsThe overall cohort included 166 248 patients with a mean (SD) age of 79.5 (8.6) years; 74 699 (47.3%) were female and 6657 (4.2%) were Black; 158 025 (95%) were treated in higher-volume sites (≥50 TAVIs) and 75 088 (45%) were treated in best-outcome sites. Modeling a volume threshold, there was no significant reduction in estimated adverse events (−34; 95% CrI, −75 to 8), while the median (IQR) driving time from the existing site to the alternate site was 22 (15-66) minutes. Transitioning care to the best outcome site in a hospital referral region resulted in an estimated 1261 fewer adverse outcomes (95% CrI, 1013-1500), while the median (IQR) driving time from the original site to the best site was 23 (15-41) minutes. Directionally similar findings were observed for Black individuals, Hispanic individuals, and individuals from rural areas.Conclusions and RelevanceIn this study, compared with the current system of care, a modeled outcome-based spoke-and-hub paradigm of TAVI care improved national outcomes to a greater extent than a simulated volume threshold, at the cost of increased driving time. To improve quality while maintaining geographic access, efforts should focus on reducing site variation in outcomes.

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The Relation between Volume and Outcome of Transcatheter and Surgical Aortic Valve Replacement: A Systematic Review and Meta-Analysis

Cited by 8 publications

References 33 publications

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

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

Severe aortic stenosis management in heart valve centres compared with primary/secondary care centres

Modeling the Association of Volume vs Composite Outcome Thresholds With Outcomes and Access to Transcatheter Aortic Valve Implantation in the US

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