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

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.