Diagnosis, Referral, Treatment Delays, and Outcomes in Veterans Affairs Patients Undergoing TAVR

Transcatheter aortic valve replacement (TAVR) improves survival and quality of life for patients with aortic valve stenosis. Despite these benefits, logistic and resource-related challenges within healthcare systems lead to delays in intervention. This study evaluates the impact of delays in diagnosis, referral, workup and treatment on survival and heart failure hospitalizations in the Veterans Affairs (VA) Health System. This retrospective cohort study of veterans who underwent TAVR at the VA Puget Sound (PUG) from January 1, 2019 to August 31, 2024. Data includes demographics, comorbidities, referral (inpatient vs outpatient), and times from initial diagnosis to TAVR. Survival was compared by wait-times and patient presentation, and a multivariate analysis was used to identify independent predictors of mortality, adjusting for age, comorbidities, and referral status. We analyzed 233 veterans, 154 (66%) outpatients, and 79 (34%) inpatients. Outpatients had a median wait time from diagnosis to treatment of 121 days intraquartile range [(IQR) 85 to 198], and inpatients 43 days [IQR 11 to 119]. Independent predictors of mortality included diagnosis to treatment >90 days hazard ratio ((HR) 2.98, p = 0.04), Stage 3+ renal insufficiency (HR 2.46, p = 0.02), chronic lung disease (HR 2.66, p = 0.02), and NYHA Class (HR 2.12, p = 0.01). STS Risk, rural location, distance from the VA and Social Vulnerability Index were not significantly associated with mortality after adjustment suggesting that mortality suggesting impact from system delays were more significant than patient-specific access barriers. Delays from diagnosis to TAVR among outpatients >90 days were associated with increased mortality. Patients whose initial diagnosis was made during a heart failure hospitalization had worse outcomes. These findings highlight the need for expediting referrals and reducing wait-times, which will potentially lead to substantial improvements in survival for patients with severe symptomatic aortic valve stenosis.