Association Between Hospital Surgical Aortic Valve Replacement Volume and Transcatheter Aortic Valve Replacement Outcomes
Association Between Hospital Surgical Aortic Valve Replacement Volume and Transcatheter Aortic Valve Replacement Outcomes
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DOI：
10.1001/jamacardio.2018.3562
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发表时间：
2018-11-01
期刊：
影响因子：
24
通讯作者：
Sedrakyan, Art
中科院分区：
文献类型：
--
作者：
Mao, Jialin;Redberg, Rita F.;Sedrakyan, Art
重要性医疗保险和医疗补助服务中心确定的经导管主动脉瓣置换术(TAVR)覆盖范围包括寻求启动或继续TAVR计划的医院的外科主动脉瓣置换术(SAVR)的容量要求。关于SAVR容量和TAVR结果之间的关联的证据有限。目的检查医院SAVR以及SAVR和TAVR联合容量与TAVR计划开始后1年、2年和整个时期内TAVR手术的患者结果的关联。设计、设置和参与者这项观察性队列研究包括2011年10月1日至2015年12月31日期间在438家医院进行的60 538例TAVR手术，其中包括医疗保险受益者。MAIN结果和测量SAVR容量、SAVR和TAVR容量、死亡、死亡或中风的风险和30天内再次住院的风险之间的关联使用分层Logistic回归模型确定。SAVR、SAVR和TAVR体积与TAVR术后1年和2年死亡率之间的关系通过采用具有稳健方差估计的多变量比例风险模型来确定。结果60538例患者中，女性29173例，男性31365例，平均年龄82.3岁(8.0岁)。SAVR使用量高的医院(年平均使用量=97)更有可能较早采用TAVR，并且随着时间的推移TAVR使用量有更高的增长(高SAVR使用量和低SAVR使用量的医院的TAVR中位数：第1年，32比19；第2年，48比28；第3年，82比38；第4年，118比54；P<；.001)。在调整后的分析中，仅医院SAVR容量高与TAVR后患者预后改善无关。当联合分析医院TAVR和SAVR容量时，在高TAVR容量的医院接受治疗的患者在TAVR后30天的死亡率较低(高TAVR和低SAVR与低TAVR和低SAVR：优势比)。0.85；95%CI，0.72~0.99；高TAVR、高SAVR与低TAVR、高SAVR：优势比0.81；95%CI，0.69~0.95)。在高SAVR容量和高TAVR容量的医院接受治疗的患者30d死亡率最低(与低SAVR容量和TAVR容量的医院相比，优势比为0.77；95%CI，0.66~0.89)。结论SAVR容量高的相关医院最有可能成为TAVR的快速采用者。医院SAVR容量本身并不与更好的TAVR结果相关。累积高容量的TAVR与TAVR后较低的死亡率有关，特别是当医院有高SAVR容量时。SAVR和TAVR病例量都很高的医院可能会取得最好的结果。
IMPORTANCE The Centers for Medicare & Medicaid Services national coverage determination for transcatheter aortic valve replacement (TAVR) includes volume requirements for surgical aortic valve replacement (SAVR) for hospitals seeking to initiate or continue TAVR programs. Evidence regarding the association between SAVR volume and TAVR outcomes is limited.OBJECTIVE To examine the association of hospital SAVR and combined SAVR and TAVR volumes with patient outcomes of TAVR procedures performed within 1 year, 2 years, and for the entire period after initiation of TAVR programs.DESIGN, SETTING, AND PARTICIPANTS This observational cohort study included 60 538 TAVR procedures performed in 438 hospitals between October 1, 2011, and December 31, 2015, among Medicare beneficiaries.MAIN OUTCOMES AND MEASURES The associations between SAVR volume, SAVR and TAVR volumes, and risks of death, death or stroke, and readmissions within 30 days were determined using a hierarchical logistic regression model adjusting for patient and hospital characteristics. The association between SAVR and SAVR and TAVR volumes and 1-year and 2-year mortality after TAVR procedures was determined using a multivariable proportional hazard model with a robust variance estimator. The associations for procedures performed within 1 year, 2 years, and for the entire period after initiation of TAVR programs were examined.RESULTS Among the 60 538 patients, 29 173 were women and 31365 were men, with a mean (SD) age of 82.3 (8.0) years. Hospitals with high SAVR volume (mean annual volume, >= 97 per year) were more likely to adopt TAVR early and had a higher growth in TAVR volumes over time (median TAVR volume by hospitals with high SAVR volume and low SAVR volume: year 1, 32 vs 19; year 2, 48 vs 28; year 3, 82 vs 38; year 4, 118 vs 54; P < .001). In adjusted analysis, high hospital SAVR volume alone was not associated with better patient outcomes after TAVR. When hospital TAVR and SAVR volumes were jointly analyzed, patients treated in hospitals with high TAVR volume had lower 30-day mortality after TAVR (high TAVR and low SAVR vs low TAVR and low SAVR: odds ratio. 0.85; 95% CI, 0.72-0.99; high TAVR and high SAVR vs low TAVR and high SAVR: odds ratio, 0.81; 95% CI, 0.69-0.95), the effect of which was more pronounced when hospitals also had high SAVR volume. Patients treated in hospitals with high SAVR volume and high TAVR volume had the lowest 30-day mortality (vs hospitals with low SAVR volume and TAVR volume: odds ratio, 0.77; 95% CI, 0.66-0.89).CONCLUSIONS AND RELEVANCE Hospitals with high SAVR volume are most likely to be fast adopters of TAVR. Hospital SAVR volume alone is not associated with better TAVR outcomes. Accumulating high volumes of TAVR is associated with lower mortality after TAVR, particularly when hospitals have high SAVR volumes. Hospitals with high caseloads of both SAVR and TAVR are likely to achieve the best outcomes.