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Canadian Journal of Cardiology

How Do We Address Health Care Inequalities for Transcatheter Aortic Valve Implantation in Canada?

  • Janarthanan Sathananthan
    Affiliations
    Centre for Heart Valve Innovation, St Paul’s Hospital, and Centre for Cardiovascular Innovation, University of British Columbia, and Vancouver General Hospital, Vancouver Coastal Health, Vancouver, British Columbia, Canada
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  • Kenneth Gin
    Correspondence
    Corresponding author: Dr Kenneth Gin, 2775 Laurel Street, 9th floor, Vancouver, British Columbia V5Z 1M9, Canada. Tel.: +1-604-875-5898.
    Affiliations
    Centre for Heart Valve Innovation, St Paul’s Hospital, and Centre for Cardiovascular Innovation, University of British Columbia, and Vancouver General Hospital, Vancouver Coastal Health, Vancouver, British Columbia, Canada
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Published:April 26, 2020DOI:https://doi.org/10.1016/j.cjca.2020.01.017
      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.
      • Mack M.J.
      • Leon M.B.
      • Thourani V.H.
      • et al.
      Transcatheter aortic-valve replacement with a balloon-expandable valve in low-risk patients.
      ,
      • Popma J.J.
      • Deeb G.M.
      • Yakubov S.J.
      • et al.
      Transcatheter aortic-valve replacement with a self-expanding valve in low-risk patients.
      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. The World Health Organization defines health inequalities as systematic differences in health care that can be avoided by appropriate policy intervention and are therefore deemed to be unfair and unjust.
      • Whitehead M.
      • Dahlgren G.
      Levelling up (part 1): a discussion paper on concepts and principles for tackling social inequalities in health.

      Current Inequalities in TAVI Care

      Wijeysundera et al., in the current issue of Canadian Journal of Cardiology, identified all transcatheter aortic valve replacement (TAVR) cases across Canada between April 1, 2014, and March 31, 2017. Wait time was defined as the duration in days from initial referral to TAVR procedure, and TAVR capacity was defined as the number of TAVR procedures per million population, per province, per fiscal year. A total of 4906 TAVR procedures across 9 provinces were performed during the study period. Wijeysundera et al. demonstrate that across 9 provinces in Canada, there is a greater than 3-fold difference in TAVI capacity among provinces. Of equal concern, there is marked variation in median wait times across Canada: from 71.5 days in Newfoundland to 190.5 and 203 days in Manitoba and Alberta, respectively.
      • Wijeysundera H.C.
      • Henning K.A.
      • Qiu F.
      • et al.
      Inequity in access to transcatheter aortic valve replacement: a pan-Canadian evaluation of wait-times.
      The inequalities highlighted in this study reflect current practice in Canada where TAVI is predominantly offered to patients of high and intermediate surgical risk. As TAVI expands to low-risk patients with increasing demand on TAVI services, these inequalities may continue to worsen. Importantly, inequalities in wait times may result in poor outcomes, particularly for patients with long wait times. Longer wait times in high-risk TAVI patients is associated with increased mortality.
      • Wijeysundera H.C.
      • Wong W.W.
      • Bennell M.C.
      • et al.
      Impact of wait times on the effectiveness of transcatheter aortic valve replacement in severe aortic valve disease: a discrete event simulation model.
      Similarly, as TAVI expands to lower-risk patients, delays in wait time may also results in worse outcomes. How do we address these health inequalities for TAVI care across Canada? Achieving an equitable health system requires 3 critical components: equal health outcomes, equal utilization of health care for those in equal need of health care, and equal access to health care for those in equal need of health care.
      • Morrison J.
      • Pons-Vigués M.
      • Bécares L.
      • et al.
      Partners from the INEQ-Cities Project. Health inequalities in European cities: perceptions and beliefs among local policymakers.

      Addressing Inequalities in TAVI Care

      TAVI can now be performed safely and reproducibly with excellent clinical outcomes.
      • Mack M.J.
      • Leon M.B.
      • Thourani V.H.
      • et al.
      Transcatheter aortic-valve replacement with a balloon-expandable valve in low-risk patients.
      However there is still variability in how patients are cared for during the pre- and postprocedural periods. The ability to increase patient capacity and reduce waiting time does not necessarily require an increase in resources. In some situations, inequalities can be reduced by improving processes of care. The Multidisciplinary, Multimodality, But Minimalist (3M) TAVR study and Edwards Benchmark Program has demonstrated that by optimizing and delivering consistent preprocedural, periprocedural, and postprocedural care, patients can achieve a high rate of safe next-day discharge.
      • Wood D.A.
      • Lauck S.B.
      • Cairns J.A.
      • et al.
      The Vancouver 3M (multidisciplinary, multimodality, but minimalist) clinical pathway facilitates safe next-day discharge home at low-, medium-, and high-volume transfemoral transcatheter aortic valve replacement centers: the 3M TAVR study.
      This has the potential to increase access to care and patient volume using current resources.
      The preprocedural workup of TAVI patients requires coordination of different health care disciplines and resources to delivery effective and efficacious TAVI care. This includes access to cardiac computed tomography, echocardiography, angiography, clinical review, frailty assessment, and a multidisciplinary heart-team meeting. Wijeysundera et al. focus on wait time from referral to procedure date. Of equal importance is monitoring referral to acceptance time to highlight any potential delay and inequalities in the workup of TAVI patients. Some delays in wait time may be related to patient workup and coordination of other medical services. Optimizing the entire patient’s TAVI journey, including pre- and postprocedural care, will help mitigate inequalities. Importantly increasing capacity or TAVI funding alone is insufficient to address inequalities.
      Although achieving consistent, reproducible care is desirable at a centre level, there is also need for national guidelines for TAVI care across Canada. Improving access to health care for TAVI patients will require both provincial and national coordination. The Canadian Cardiovascular Society-Sponsored National Quality Report: Transcatheter Aortic Valve Implantation (Released October 2019) provides an important national perspective.
      • Lauck S.
      • Stub D.
      • Webb J.
      Monitoring wait times for transcatheter aortic valve implantation: a need for national benchmarks.
      Current models of care are delivered on a provincial level. In British Columbia, TAVI is coordinated through Cardiac Services British Columbia (CSBC), which is responsible for funding, coordinating, monitoring, and evaluating outcomes for the provincial transcatheter heart valve program. This model regularly monitors waiting times, and CSBC can coordinate resources in an attempt to mitigate inequalities across the province.
      • Lauck S.
      • Stub D.
      • Webb J.
      Monitoring wait times for transcatheter aortic valve implantation: a need for national benchmarks.
      Although such a model is beneficial on a provincial level, a similar model may be beneficial on a national level to monitor and address inequalities among provinces. Coordination of TAVI funding on a national level would be challenging. However, there may be value in national governance of TAVI care to monitor waiting times and capacity across Canada. This would allow ongoing monitoring of inequalities across the country. This is particularly important as TAVI expands to low-risk patients, and inequalities may continue to widen across the country. In addition, as volume increases, there may also be inadequate capacity in some provinces to provide adequate care. National governance may also be beneficial, and patients may need to be transferred to other provinces for TAVI care. Transfer of patients to other provinces already occurs for other percutaneous procedures. Some provinces have no access to percutaneous mitral plication, and eligible patients are not uncommonly transferred to other provinces for care.

      Conclusions

      One of the basic foundations of medical care is that each individual should have equal access to health care. Ensuring that all patients in Canada have equal and equitable access to TAVI will be a priority for clinicians, policy makers, and funding organizations. This is of importance as TAVI increasingly becomes an accepted alternative to surgical aortic valve replacement for patients with severe calcific aortic stenosis.

      Funding Sources

      The authors report no relevant funding sources.

      Disclosures

      Dr Sathananthan has received speaking fees and is a consultant to Edwards Lifesciences.
      Dr Gin has no conflicts of interest to disclose.

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