In rural Florida, TAVR use lower, in-hospital mortality higher vs. rest of state
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Patients in rural Florida were less likely to undergo transcatheter aortic valve replacement and more likely to have in-hospital mortality after TAVR compared with patients from more populated areas in the state, researchers reported.
Those in rural areas also had longer driving distance and time to reach the nearest TAVR center compared with those in more densely populated areas, according to the study published in Circulation: Cardiovascular Quality and Outcomes.
“Although no standard metrics for access to TAVR procedures (eg, time or distance) have been established, the recent TAVR consensus statement does recognize that some centers performing less than the annual minimum will need to be maintained to meet the needs of underserved populations,” Abdulla A. Damluji, MD, PhD, MPH, assistant professor of medicine at Johns Hopkins University School of Medicine and interventional cardiologist and member of the structural heart program at the Inova Medical Group in Alexandria, Virginia, and colleagues wrote. “In light of these expert statements and the inherent challenges of delivering health care across states like Florida, the maintenance of optimal procedural outcomes without compromising health care access remains an active area of debate. This is an especially difficult issue for cardiovascular procedures like TAVR that require a high degree of technical expertise and a multidisciplinary team of health care professionals.”
The researchers analyzed 6,531 patients (mean age, 82 years; 43% women; 91% white) who underwent TAVR in Florida from 2011 to 2016. The primary outcomes were travel time and distance to a TAVR-capable center and rates of TAVR utilization and mortality, stratified by population per square miles of land.
TAVR in rural vs. urban areas
Researchers observed that patients living in the lowest category for population density (fewer than 50 residents per square mile) were younger, more likely to be men and less likely to be a racial minority compared with those living in areas with more population density.
According to the study, patients living in low-population density areas traveled greater average travel distance (43.5 miles further; 95% CI, 35.6-51.4) and longer time (45.6 minutes longer; 95% CI, 38.3-52.9) to a TAVR center compared with patients living in more urban areas.
Moreover, age- and sex-adjusted in-hospital mortality among patients who lived in the areas with the lowest population density was higher compared with those living in high-population density areas (5% vs. 1%; adjusted OR after excluding uninhabited areas = 6.13; 95% CI, 1.97-19.1).
After researchers excluded uninhabited land from the analysis, the rate of TAVR procedure utilization per 100,000 residents was lower in areas with low-population density areas and increased as population density increases (7 procedures per 100,000 vs. 45 procedures per 100,000; P for pairwise comparisons < .001).
‘Creative solutions’
“Guidelines should reflect the balance between quality standards and health care access for communities at risk for underdiagnosis and undertreatment of aortic valve disease,” the researchers wrote. “While creative solutions like ride-sharing platforms could be used to improve access, this approach has produced mixed results in the primary care setting. Other creative solutions to address health care access include the establishment of local primary valvular heart disease care centers in low-population density areas to promote and improve screening, diagnosis and prognostication of valvular heart disease, and that will ultimately lead to higher referral to specialized TAVR centers in urban areas.
“If preprocedural workup and postprocedure care can be done competently at the local level and if telemedicine can allow meetings with TAVR center personnel for those living in low-population density areas, then the need to travel to a TAVR center may become a one-time occurrence,” the researchers wrote.
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