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Canadian Journal of Cardiology

Inequity in Access to Transcatheter Aortic Valve Replacement: A Pan-Canadian Evaluation of Wait-Times

Published:October 24, 2019DOI:https://doi.org/10.1016/j.cjca.2019.10.018

      Abstract

      Background

      There has been an exponential increase in the demand for transcatheter aortic valve replacement (TAVR). Our goal was to examine trends in TAVR capacity and wait-times across Canada.

      Methods

      All TAVR cases were identified from April 1, 2014, to March 31, 2017. Wait-time was defined as the duration in days from the initial referral to the TAVR procedure. TAVR capacity was defined as the number of TAVR procedures per million population/province/fiscal year. We performed multivariable multilevel Cox proportional hazards modelling of the time to TAVR as the dependant variable and the effect of provinces as random effects. We quantified the variation in wait-times among provinces using the median hazard ratio.

      Results

      We identified a total of 4906 TAVR procedures across 9 provinces. Despite a year over year increase in overall capacity, there was a greater than 3-fold difference in capacity between provinces. Crude median wait-times increased over time in all provinces, with marked variation from 71.5 days in Newfoundland to 190.5 and 203 days in Manitoba and Alberta, respectively. This suggests increasing demand outpaced the growth in capacity. We found a median hazard ratio of 1.62, indicating that in half of the possible pairwise comparisons, the time to TAVR for identical patients was at least 62% longer between different provinces.

      Conclusion

      We found substantial geographic inequity in TAVR access. This calls for policy makers, clinicians, and administrators across Canada to address this inequity through revaluation of provincial funding mechanisms, as well as implementation of efficient care pathways.

      Résumé

      Contexte

      La demande pour des interventions de remplacement valvulaire aortique par cathéter (RVAC) affiche une croissance exponentielle. Nous avons examiné les tendances en matière de capacité d’exécution des interventions de RVAC et les temps d’attente au Canada.

      Méthodologie

      Nous avons recensé tous les RVAC effectués entre le 1er avril 2014 et le 31 mars 2017. Le temps d’attente était défini par le nombre de jours entre la demande de consultation initiale et l’intervention de RVAC. La capacité en matière de RVAC était définie par le nombre d’interventions de RVAC effectuées pour chaque tranche d’un million d’habitants, par province et par exercice financier. Nous avons réalisé une analyse multivariée à plusieurs niveaux fondée sur un modèle à risques proportionnels de Cox en utilisant le temps d’attente avant le RVAC comme variable dépendante et la province comme effet aléatoire. Nous avons quantifié la variation des temps d’attente d’une province à l’autre au moyen du rapport des risques instantanés médian.

      Résultats

      Nous avons relevé un nombre total de 4 906 RVAC dans neuf provinces. Malgré une augmentation de la capacité globale d’année en année, la capacité d’une province à l’autre variait d’un facteur supérieur à trois. Le temps d’attente brut médian a augmenté au fil des ans dans toutes les provinces et variait de façon marquée d’une province à l’autre, allant de 71,5 jours à Terre-Neuve à 190,5 jours au Manitoba et à 203 jours en Alberta. Ces données semblent indiquer que la demande augmente plus rapidement que la capacité. Le rapport des risques instantanés médian s’établissait à 1,62, ce qui signifie que pour la moitié des comparaisons par paire de provinces possibles, le temps d’attente pour subir un RVAC dans des cas identiques variait d’au moins 62 % d’une province à l’autre.

      Conclusion

      Les résultats de notre analyse révèlent une grande iniquité géographique dans l’accès au RVAC. Il conviendrait donc que les décideurs, les cliniciens et les administrateurs de partout au Canada s’attaquent à cette iniquité en réévaluant les mécanismes de financement provinciaux et en mettant en place des parcours de soins efficients.
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      Linked Article

      • How Do We Address Health Care Inequalities for Transcatheter Aortic Valve Implantation in Canada?
        Canadian Journal of CardiologyVol. 36Issue 6
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          Transcatheter aortic valve implantation (TAVI) is a revolutionary technology for the treatment of patients with severe calcific aortic stenosis. TAVI may become the preferred therapy for the majority of patients, with recent evidence demonstrating that TAVI is beneficial for all patients irrespective of surgical risk.1,2 Although there have been rapid improvements in device technology, technique, and patient care, there remain challenges in the care of patients who have undergone TAVI. Similar to any medical therapy, there is a risk of health inequalities.
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