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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Article info
Publication history
Published online: October 24, 2019
Accepted:
October 21,
2019
Received:
July 11,
2019
Footnotes
See editorial by Sathananthan and Gin, pages 797-798 of this issue.
See page 850 for disclosure information.
Identification
Copyright
© 2019 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
ScienceDirect
Access this article on ScienceDirectLinked Article
- How Do We Address Health Care Inequalities for Transcatheter Aortic Valve Implantation in Canada?Canadian Journal of CardiologyVol. 36Issue 6
- PreviewTranscatheter 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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