Will a Conservative Case Selection Strategy Improve Hospital-Level TAVR Performance Metrics?

Current national performance metrics rank transcatheter aortic valve replacement (TAVR) centers based on risk-adjusted outcomes. This could make operators/centers less inclined to offer TAVR in high-risk cases.

We used simulation models based on registry data to explore whether avoiding high-risk TAVR cases would improve the hospitals' comparative risk-adjusted TAVR outcomes. This multicenter, retrospective cohort study included all adults (≥18 years) who underwent TAVR in the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy registry in 2021. We evaluated hospital-level, risk-adjusted outcomes, before and after simulating the omission of the top 10% highest-risk patients. The primary outcome was a 30-day composite of death, stroke, VARC major/life-threatening/disabling bleeding, renal failure, or moderate/severe para-valvular leak. The secondary outcome was 30-day death. We used the mean difference±SD in the win ratio and observed/expected ratio for evaluation of the primary and secondary outcomes, respectively.

There were 43 907 TAVR cases with available primary outcome data and 56 982 cases with available secondary outcome data. Median age was 79 (73-84) years, 57% were men, and 93% were White race. Our simulation demonstrates that, on average, excluding the top 10% highest-risk patients from centers' case mix would not change their hospital-level, risk-adjusted win ratio (mean difference, 0.002±0.067; P=0.60) or observed/expected ratio (mean difference, -0.003±0.633; P=0.90).

Hospital-level, risk-adjusted TAVR outcomes did not consistently improve with simulated strategies of avoiding the highest-risk cases. Operators and centers can be reassured that they can continue to offer TAVR to high-risk patients, as clinically indicated, without the sole focus on being penalized via quality measures.