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

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Summary
This summary is machine-generated.

Avoiding high-risk transcatheter aortic valve replacement (TAVR) cases does not improve hospital performance metrics. TAVR centers can continue treating high-risk patients without fear of penalties from quality measures.

Keywords:
aortic valvebenchmarkinghealth metricshospitalspublic reporting of healthcare dataregistriestranscatheter aortic valve replacement

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Area of Science:

  • Cardiovascular Medicine
  • Interventional Cardiology
  • Health Services Research

Background:

  • National performance metrics for transcatheter aortic valve replacement (TAVR) rank centers using risk-adjusted outcomes.
  • This ranking system may discourage TAVR operators and centers from treating high-risk patients.

Purpose of the Study:

  • To investigate if excluding high-risk TAVR cases would improve hospital-level, risk-adjusted TAVR outcomes.
  • To provide evidence for TAVR centers regarding the treatment of high-risk individuals.

Main Methods:

  • A multicenter, retrospective cohort study using 2021 data from the STS/ACC Transcatheter Valve Therapy registry.
  • Simulation models were used to assess outcomes before and after excluding the highest-risk 10% of TAVR patients.
  • Primary outcome: 30-day composite of death, stroke, major bleeding, renal failure, or moderate/severe para-valvular leak. Secondary outcome: 30-day death.

Main Results:

  • The study analyzed 43,907 TAVR cases for the primary outcome and 56,982 for the secondary outcome.
  • Simulating the exclusion of the top 10% highest-risk patients did not significantly alter hospital-level risk-adjusted win ratios (mean difference, 0.002±0.067; P=0.60).
  • Similarly, the observed/expected ratio remained unchanged (mean difference, 0.003±0.633; P=0.90).

Conclusions:

  • Strategies of avoiding the highest-risk TAVR patients did not consistently improve hospital-level risk-adjusted outcomes.
  • TAVR operators and centers can confidently offer the procedure to high-risk patients as clinically indicated, without undue concern over quality measure penalties.