Association of Hospital Surgical Aortic Valve Replacement Quality With 30-Day and 1-Year Mortality After Transcatheter Aortic Valve Replacement
Association of Hospital Surgical Aortic Valve Replacement Quality With 30-Day and 1-Year Mortality After Transcatheter Aortic Valve Replacement
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DOI：
10.1001/jamacardio.2018.4051
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发表时间：
2019-01-01
期刊：
影响因子：
24
通讯作者：
Yeh, Robert W.
中科院分区：
文献类型：
--
作者：
Kundi, Harun;Popma, Jeffrey J.;Yeh, Robert W.
重要性：经导管主动脉瓣置换术（TAVR）的住院结果可能取决于心脏手术患者的评估质量、人员、手术和术后护理。目的：我们试图评估那些实施手术主动脉瓣置换术（SAVR）患者预后较好的医院，在启动TAVR项目后，是否也获得了较好的TAVR预后。设计、环境和参与者本国家队列包括65岁及以上的美国患者。该分析使用了2010年1月1日至2015年9月29日期间收集的医疗保险和医疗补助服务中心的医疗保险提供者和审查数据。只有在2011年9月1日之前实施至少1例savr，并在此日期之后实施至少1例TAVR的医院被纳入分析。数据分析于2018年6月至2018年8月完成。干预措施：孤立主动脉瓣置换术。主要结局和测量采用tavr前的医院风险调整后的SAVR 30天死亡率作为SAVR质量的替代指标。将基线医院风险调整后的SAVR死亡率按四分位数分层后，检查30天和1年的TAVR死亡率。结果519家医院共实施51 924例TAVR手术，其中1四分位数（风险调整后SAVR死亡率最低）实施19 798例，2四分位数（风险调整后SAVR死亡率最高）实施7663例，3四分位数（风险调整后SAVR死亡率最高）实施10 180例，4四分位数（风险调整后SAVR死亡率最高）实施14 283例。观察到的30天死亡率随着基线医院SAVR风险调整死亡率的增加而持续增加（四分位数为1,917例患者[4.6%）；四分位数2,381 [5.0%]；四分位数3,521 [5.1%]；四分位数4800 [5.6%]；P < 0.001)。在1年死亡率中也观察到相同的模式(四分位数1,3359[17.0%]，四分位数2,1337 [17.5%]；四分位数3,1852 [18.2%]；四分位数4,2652 [18.6%]；P < 0.001)。多变量分析后，与SAVR死亡率最低的四分位数相比，在基线SAVR死亡率较高的医院接受TAVR继续与较高的30天死亡率相关（优势比：四分位数2,1.02 [95% CI, 0.87-1.21]；四分位数3,1.13 [95% CI, 1.02-1.26]；四分位数4,1.23 [95% CI, 1.07-1.40]; P = 0.02）和1年死亡率相关(风险比：四分位数2,1.04 [95% CI, 0.92-1.17]；四分位数3,1.14 [95% Cl, 1.02-1.28]；四分位数4,1.16 [95% CI, 1.05-1.28]；P = .02)。结论和相关性：在启动TAVR方案后，SAVR死亡率较高的医院也有较高的短期和长期TAVR死亡率。心脏外科护理的质量可能与医院在新结构心脏病项目中的表现有关。
IMPORTANCE Hospital 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.OBJECTIVES We 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 PARTICIPANTS This 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 1SAVR 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.INTERVENTIONS Isolated aortic valve replacements.MAIN OUTCOMES AND MEASURES Hospital 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.RESULTS A 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% Cl, 1.02-1.28]; quartile 4, 1.16 [95% CI, 1.05-1.28]; P = .02).CONCLUSIONS AND RELEVANCE Hospitals 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.