Abstract
Background
Transcatheter aortic valve replacement (TAVR) has become the standard of care for
a wide spectrum of patients with severe aortic stenosis. However, there are wide variations
in access to TAVR among jurisdictions. It is unknown if such variation is associated
with differences in postprocedural outcomes. Our objective was to determine whether
differences in health care delivery in jurisdictions with high vs low access of care
to TAVR translate to differences in postprocedural outcomes.
Methods
In this observational, retrospective cohort study, we identified all Ontario and New
York State residents greater than 18 years of age who received TAVR from January 1,
2012, to December 31, 2018. Our primary outcomes were post-TAVR 30 day in-hospital
mortality and all-cause readmissions. Using indirect standardization, we calculated
the observed vs expected outcomes for New York patients, had they been treated in
Ontario.
Results
Our cohort consisted of 16,814 TAVR patients at 36 hospitals in New York State and
5007 TAVR patients at 11 hospitals in Ontario. In Ontario, TAVR access rates increased
from ∼18.2 TAVR per million in 2012 to 87.4 TAVR per million in 2018, whereas for
New York State, the rates increased from 31.9 to 220.4 TAVR per million. For 30-day
mortality, 3.1% of Ontario TAVR patients had an in-hospital death, compared with 2.5%
of New York patients. With adjustment, this translated to an observed-expected ratio
of 0.70 (95% confidence interval [CI], 0.54-0.92) for New York patients.
Conclusions
Having greater access to TAVR may be associated with improved outcomes, potentially
because of intervention earlier in the trajectory of the disease.
Résumé
Contexte
L’implantation transcathéter de la valve aortique (ITVA) est maintenant la norme de
soins chez la majorité des patients atteints de sténose aortique grave, mais l’accès
à l’ITVA varie considérablement d’une région à l’autre. Or, on ne sait pas si cette
variation est associée à des différences quant aux résultats après l’intervention.
Notre objectif était donc de déterminer si les résultats après une ITVA varient selon
que l'accès est élevé ou faible dans une région donnée.
Méthodologie
Dans cette étude de cohorte observationnelle et rétrospective, nous avons répertorié
tous les résidents de l’Ontario et de l’État de New York âgés de plus de 18 ans qui
avaient subi une ITVA entre le 1er janvier 2012 et le 31 décembre 2018. Les principaux résultats après une ITVA étaient
la mortalité hospitalière et les réadmissions toutes causes confondues à 30 jours.
En utilisant la standardisation indirecte, nous avons calculé les résultats observés
par rapport aux résultats attendus pour les patients de New York, s’ils avaient été
traités en Ontario.
Résultats
La cohorte était composée de 16 814 patients ayant subi une ITVA dans 36 hôpitaux
de l’État de New York et de 5007 patients ayant subi une ITVA dans 11 hôpitaux de
l’Ontario. Dans cette province, les taux d’accès à l’ITVA sont passés d’environ 18,2
par million d’habitants en 2012 à 87,4 par million d’habitants en 2018, tandis que
pour l’État de New York, les taux ont augmenté de 31,9 à 220,4 par million d’habitants.
En ce qui concerne la mortalité à 30 jours, 3,1 % des patients ayant subi une ITVA
en Ontario sont décédés à l’hôpital contre 2,5 % des patients de l’État de New York.
Après ajustement, le rapport des résultats observés/attendus était de 0,70 (intervalle
de confiance à 95 % [IC] : 0,54-0,92) pour les patients de New York.
Conclusions
Un meilleur accès à l’ITVA peut être associé à de meilleurs résultats, potentiellement
en raison d’une intervention plus précoce dans la trajectoire de la maladie.
Graphical abstract
Graphical Abstract
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Article info
Publication history
Published online: February 01, 2023
Accepted:
January 19,
2023
Received:
November 3,
2022
Publication stage
In Press Journal Pre-ProofFootnotes
See editorial by Noble et al., pages xxx-xxx of this issue.
See page 7 for disclosure information.
Identification
Copyright
© 2023 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
