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Sex differences in 30-day readmission rates, etiology, and predictors after transcatheter aortic valve replacement.

ABSTRACT: BACKGROUND:The aim of this study is to analyze sex-specific readmission rates, etiology, and predictors of readmission after transcatheter aortic valve replacement (TAVR). Readmissions after TAVR are common, contributing to increased health care utilization and costs. Many factors have been discovered as predictors of readmission; however, sex-specific disparities in readmission rates are limited. METHODS:Between January 2012 and September 2015, adult patients after TAVR were identified using appropriate international classifications of diseases, ninth revision, clinical modification from the National Readmission Database. Incidence of unplanned 30-days readmission rate was the primary outcome of this study. In addition, this study includes sex-specific etiology and predictors of readmissions. Multivariate logistic regression was performed to analyze adjusted readmission rates. Hierarchical 2-level logistic models were used to evaluate predictors of readmission. RESULTS:Readmission rate at 30 days was 17.3%, with slightly higher readmission rates in women (OR 1.09; CI: 1.01-1.19, p < 0.001) after multivariate adjusted analysis. Noncardiac causes were responsible for most readmissions in both genders. Etiologies for readmissions such as arrhythmias, pulmonary complications, and infections were slightly higher in women, whereas heart failure and bleeding complications were higher in men. History of heart failure, atrial fibrillation, prior pacemaker, and renal failure significantly strongly predicted readmissions in both genders. CONCLUSION:Women undergoing TAVR have slightly higher 30-day all-cause readmission rates. These results indicate that women require more attention compared to men to prevent 30-day readmission. In addition, risk stratification for men and women based on predictors will help identify high-risk men and women for readmissions.

SUBMITTER: Doshi R

PROVIDER: S-EPMC6890955 | biostudies-literature | 2019 Jul - Aug

REPOSITORIES: biostudies-literature

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Sex differences in 30-day readmission rates, etiology, and predictors after transcatheter aortic valve replacement.

Doshi Rajkumar R Taha Mohamed M Dave Mihir M Desai Rupak R Gullapalli Nageshwara N

Indian heart journal 20190701 4

<h4>Background</h4>The aim of this study is to analyze sex-specific readmission rates, etiology, and predictors of readmission after transcatheter aortic valve replacement (TAVR). Readmissions after TAVR are common, contributing to increased health care utilization and costs. Many factors have been discovered as predictors of readmission; however, sex-specific disparities in readmission rates are limited.<h4>Methods</h4>Between January 2012 and September 2015, adult patients after TAVR were iden ...[more]

PMID: 31779855

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Project description:ImportanceHospital outcomes for transcatheter aortic valve replacement (TAVR) may be dependent on the quality of evaluation, personnel, and procedural and postprocedural care common to patients undergoing cardiac surgery.ObjectivesWe sought to assess whether those hospitals with better patient outcomes for surgical aortic valve replacement (SAVR) subsequently achieved better TAVR outcomes after launching TAVR programs.Design, setting, and participantsThis national cohort included US patients 65 years and older. The analysis used the Centers for Medicare and Medicaid Services' Medicare Provider and Review data collected between January 1, 2010, and September 29, 2015. Only hospitals performing at least 1 SAVR prior to September 1, 2011, and performing at least 1 TAVR after this date were included in the analysis. Data analysis was completed from June 2018 to August 2018.InterventionsIsolated aortic valve replacements.Main outcomes and measuresHospital risk-adjusted 30-day mortality for SAVR in the pre-TAVR period was used as a surrogate for SAVR quality. Thirty-day and 1-year TAVR mortality rates were examined after stratification by quartile of baseline hospital risk-adjusted SAVR mortality.ResultsA total of 51 924 TAVR procedures were performed in 519 hospitals, of which 19 798 were performed at hospitals in quartile 1 (the lowest risk-adjusted SAVR mortality rate), 7663 were performed in quartile 2, 10 180 were performed in quartile 3, and 14 283 were performed in quartile 4 (the highest risk-adjusted SAVR mortality rate). Observed mortality rates at 30 days consistently increased with increasing baseline hospital SAVR risk-adjusted mortality (quartile 1, 917 patients [4.6%]; quartile 2, 381 [5.0%]; quartile 3, 521 [5.1%]; quartile 4, 800 [5.6%]; P < .001). The same pattern was observed in 1-year mortality (quartile 1, 3359 [17.0%]; quartile 2, 1337 [17.5%]; quartile 3, 1852 [18.2%]; quartile 4, 2652 [18.6%]; P < .001). After multivariable analysis, compared with the lowest quartile of SAVR mortality, undergoing TAVR at a hospital with higher baseline SAVR mortality continued to be associated with higher 30-day mortality (odds ratios: quartile 2, 1.02 [95% CI, 0.87-1.21]; quartile 3, 1.13 [95% CI, 1.02-1.26]; quartile 4, 1.23 [95% CI, 1.07-1.40]; P = .02) and 1-year mortality (hazard ratios: quartile 2, 1.04 [95% CI, 0.92-1.17]; quartile 3, 1.14 [95% CI, 1.02-1.28]; quartile 4, 1.16 [95% CI, 1.05-1.28]; P = .02).Conclusions and relevanceHospitals with higher SAVR mortality rates also had higher short-term and long-term TAVR mortality after initiating TAVR programs. Quality of cardiac surgical care may be associated with a hospital's performance with new structural heart disease programs.

Project description:ImportanceWith the approval of transcatheter aortic valve replacement (TAVR) for patients with severe symptomatic aortic stenosis at intermediate surgical risk, TAVR volume is projected to increase exponentially in the United States. The 30-day readmission rate for TAVR was recently reported at 17.9%. The association between institutional TAVR volume and the 30-day readmission metric has not been examined.ObjectiveTo assess the association between hospital TAVR volume and 30-day readmission.Design, setting, and participantsIn this observational study, we used the 2014 Nationwide Readmissions Database to identify hospitals with established TAVR programs (performing at least 5 TAVRs in the first quarter of 2014). Based on annual TAVR volume, hospitals were classified as low (<50), medium (≥50 to <100), and high (≥100) volume. Rates, causes, and costs of 30-day readmissions were compared between low-, medium-, and high-volume hospitals. Data were analyzed from November to December 2016.ExposureTranscatheter aortic valve replacement.Main outcomes and measuresThirty-day readmissions.ResultsOf 129 hospitals included in this study, 20 (15.5%) were categorized as low volume, 47 (36.4%) as medium volume, and 62 (48.1%) as high volume. Of 16 252 index TAVR procedures, 663 (4.1%), 3067 (18.9%), and 12 522 (77.0%) were performed at low-, medium-, and high-volume hospitals, respectively. Thirty-day readmission rates were significantly lower in high-volume compared with medium-volume (adjusted odds ratio, 0.76; 95% CI, 0.68-0.85; P < .001) and low-volume (adjusted odds ratio, 0.75; 95% CI, 0.60-0.92; P = .007) hospitals. Noncardiac readmissions were more common in low-volume hospitals (65.6% vs 60.6% in high-volume hospitals), whereas cardiac readmissions were more common in high-volume hospitals (39.4% vs 34.4% in low-volume hospitals). There were no significant differences in length of stay and costs per readmission among the 3 groups (mean [SD], 5.5 [5.0] days vs 5.9 [7.5] days vs 6.0 [5.8] days; P = .74, and $13 886 [18 333] vs $14 135 [17 939] vs $13 432 [15 725]; P = .63, respectively).Conclusions and relevanceWe report for the first time, to our knowledge, an inverse association between hospital TAVR volume and 30-day readmissions. Lower readmission at higher-volume hospitals was associated with significantly lower cost to the health care system.

Project description:ImportanceQuestions have recently arisen as to whether 30-day mortality is a reasonable metric for understanding institutional practice differences after transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR).ObjectiveTo examine the utility of 30-day vs 90-day mortality after TAVR and SAVR as a mortality quality metric.Design, setting, and participantsThis nationally representative, multicenter, cohort study analyzed data from Medicare beneficiaries undergoing TAVR and SAVR procedures from January 1, 2012, to December 31, 2015. Concomitant coronary artery bypass grafting and other heart valve or other major open-heart procedures were excluded. Hospitals that performed fewer than 50 TAVR or 70 SAVR procedures per year were excluded to ensure reliable estimates and to reduce the risks of inflated results because of small institutional sample sizes. Data were analyzed from October 2018 to August 2019.ExposuresHospitals were ranked into top- (10%), middle- (80%), and bottom-performing (10%) groups based on their 4-year mean 30-day mortality.Main outcomes and measuresChanges in hospital performance rankings at 90 days and 1 year and correlation of 30- and 90-day mortality with 1-year mortality were examined.ResultsA total of 30 329 TAVR admissions at 184 hospitals and 26 021 SAVR admissions at 191 hospitals were evaluated. For TAVR, 40 hospitals (21.7%) changed performance rankings at 90 days: 13 (48.1%) in the top-performing group and 8 (29.6%) in the bottom-performing group. At 1 year, 56 hospitals (30.4%), which included 21 (77.8%) in the top-performing group and 12 (44.4%) in the bottom-performing group, changed rankings. Similar findings were observed for SAVR, with an overall 90-day conversion rate of 17.3% and a 1-year rate of 30.3%. These findings persisted after adjusting for the differences in patient risk profiles among the 3 groups. Capturing 90-day events was also more robustly informative regarding expected 1-year outcomes after both TAVR and SAVR, largely owing to the observed plateau in the instantaneous hazard observed beyond this point.Conclusions and relevanceThe findings suggest that evaluation of hospital performance based on 30-day mortality may underestimate outcomes and therefore substantially misrepresent institutional performance after TAVR and SAVR compared with 90-day mortality, even after risk adjustment. Although 30-day mortality has been validated, 90-day mortality may be a more reliable outcome metric for measuring hospital performance and capturing procedure-related mortality.

Dataset Information

Sex differences in 30-day readmission rates, etiology, and predictors after transcatheter aortic valve replacement.

Publications

Sex differences in 30-day readmission rates, etiology, and predictors after transcatheter aortic valve replacement.

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