30-day readmissions lower at high-volume TAVR centers

NEW ORLEANS — A new study highlights an inverse association between hospital transcatheter aortic valve replacement volume and 30-day readmission rates.

Thirty-day readmission rates were significantly lower at high-volume centers compared with those at which fewer TAVR procedures were performed, but volume appeared to have no effect on length of hospital stay or costs per readmission, according to data presented at the Society for Cardiovascular Angiography and Interventions Annual Meeting and published simultaneously in JAMA Cardiology.

“As new TAVR programs open across the country, these data will guide policymakers to identify targets for optimizing and standardizing TAVR outcomes across hospitals,” Sahil Khera, MD, MPH, from New York Medical College, Valhalla, and colleagues wrote in JAMA Cardiology.

The researchers utilized data from the 2014 Nationwide Readmissions Database to identify hospitals with established TAVR programs that had performed at least five TAVR procedures during the first quarter of 2014. Of the 129 U.S. hospitals included in the analysis, 48.1% were categorized as high volume ( 100 procedures), 36.4% as medium volume (50 to < 100) and 15.5% as low volume (< 50).

A total of 16,252 TAVR procedures were performed: 77% at high-volume hospitals, 18.9% at medium-volume hospitals and 4.1% at low-volume hospitals. The mean age of the patients was 81 years, and 46% were women. Patients treated at medium- and high-volume hospitals had a lower burden of comorbidities at baseline. TAVR performed via endovascular access was more common at higher-volume hospitals, whereas transapical TAVR was more common at lower-volume hospitals.

The overall incidence of 30-day readmissions was 16.4%. Rates of 30-day readmission were significantly lower at higher-volume hospitals, compared with medium-volume hospitals (adjusted OR = 0.76; 95% CI, 0.68-0.85) and low-volume hospitals (adjusted OR = 0.75; 95% CI, 0.6-0.92).

Khera and colleagues noted that the inverse association between TAVR volume and 30-day readmissions in this study “is potentially of concern.” The reasons underlying the inverse association are “likely multifactorial,” and depend on patient factors, operator factors, hospital systems and community factors, according to the researchers.

More than 61% of readmissions were related to noncardiac causes. The 30-day noncardiac readmission rate was 65.6% at low-volume hospitals vs. 60.5% at high-volume hospitals. The 30-day rate of cardiac readmissions was 39.4% at high-volume hospitals vs. 34.4% at low-volume hospitals.

The median time to readmission was 9 days.

In other results, the mean length of stay ranged from 5.5 days at low-volume hospitals to 6 days at high-volume hospitals (P = .74 for comparison), and the mean cost per readmission ranged from $14,135 at medium-volume hospitals to $13,432 at high-volume hospitals (P = .63 for comparison).

“We calculated that if the high-volume hospitals had similar readmission rates as low-volume hospitals, the excess readmissions would have increased the annual health care expenditure by more than $6.5 million,” Khera and colleagues wrote.

The researchers noted that TAVR volume “is projected to increase exponentially in the United States,” as the procedure is now approved for use in patients with severe symptomatic aortic stenosis at intermediate surgical risk. “The 30-day readmission rate for TAVR was recently reported at 17.9%,” they wrote.

John D. Carroll, MD , professor of medicine/cardiology, director of interventional cardiology, and co-director of the Cardiac and Vascular Center at University of Colorado Denver, Anschutz Medical Campus, Aurora, discussed the findings in an accompanying editorial.

“Rehospitalization after TAVR is a multifaceted issue and includes some opportunities for sites to modify those factors that contribute to the need for rehospitalization. For low-volume and higher-volume programs, the most constructive approach is to promote best practices and focus TAVR programs to analyze their outcomes, including readmission rates, compare them with national benchmarks and take actions that are likely to improve their performance and reduce unwanted outcomes such as readmissions,” he wrote. “The Society of Thoracic Surgeons/American College of Cardiology [Transcatheter Valve Therapy] Registry has the principle goal to enable TAVR programs to achieve the highest quality of care. A commitment to quality measurement and improvements should be a requirement for TAVR programs and their National Coverage Determination-mandated participation in the TVT Registry provides them with the data they need.” – by Katie Kalvaitis

Reference s :

Kolte D, et al. Best of the Best Abstracts: B-002. Presented at: Society for Cardiovascular Angiography and Interventions Annual Meeting; May 10-13, 2017; New Orleans.

Carroll JD. JAMA Cardiol. 2017;doi:10.1001/jamacardio.2017.1650.

Khera S, et al. JAMA Cardiol. 2017;doi:10.1001/jamacardio.2017.1630.

Disclosure: Carroll is a member of the steering committee of the STS/ACC TVT Registry. Khera and colleagues report no relevant financial disclosures.