New York Medical College, Valhalla.
Brown University, Providence, Rhode Island.
JAMA Cardiol. 2017 Jul 1;2(7):732-741. doi: 10.1001/jamacardio.2017.1630.
IMPORTANCE: With the approval of transcatheter aortic valve replacement (TAVR) for patients with severe symptomatic aortic stenosis at intermediate surgical risk, TAVR volume is projected to increase exponentially in the United States. The 30-day readmission rate for TAVR was recently reported at 17.9%. The association between institutional TAVR volume and the 30-day readmission metric has not been examined. OBJECTIVE: To assess the association between hospital TAVR volume and 30-day readmission. DESIGN, SETTING, AND PARTICIPANTS: In this observational study, we used the 2014 Nationwide Readmissions Database to identify hospitals with established TAVR programs (performing at least 5 TAVRs in the first quarter of 2014). Based on annual TAVR volume, hospitals were classified as low (<50), medium (≥50 to <100), and high (≥100) volume. Rates, causes, and costs of 30-day readmissions were compared between low-, medium-, and high-volume hospitals. Data were analyzed from November to December 2016. EXPOSURE: Transcatheter aortic valve replacement. MAIN OUTCOMES AND MEASURES: Thirty-day readmissions. RESULTS: Of 129 hospitals included in this study, 20 (15.5%) were categorized as low volume, 47 (36.4%) as medium volume, and 62 (48.1%) as high volume. Of 16 252 index TAVR procedures, 663 (4.1%), 3067 (18.9%), and 12 522 (77.0%) were performed at low-, medium-, and high-volume hospitals, respectively. Thirty-day readmission rates were significantly lower in high-volume compared with medium-volume (adjusted odds ratio, 0.76; 95% CI, 0.68-0.85; P < .001) and low-volume (adjusted odds ratio, 0.75; 95% CI, 0.60-0.92; P = .007) hospitals. Noncardiac readmissions were more common in low-volume hospitals (65.6% vs 60.6% in high-volume hospitals), whereas cardiac readmissions were more common in high-volume hospitals (39.4% vs 34.4% in low-volume hospitals). There were no significant differences in length of stay and costs per readmission among the 3 groups (mean [SD], 5.5 [5.0] days vs 5.9 [7.5] days vs 6.0 [5.8] days; P = .74, and $13 886 [18 333] vs $14 135 [17 939] vs $13 432 [15 725]; P = .63, respectively). CONCLUSIONS AND RELEVANCE: We report for the first time, to our knowledge, an inverse association between hospital TAVR volume and 30-day readmissions. Lower readmission at higher-volume hospitals was associated with significantly lower cost to the health care system.
重要性：随着经导管主动脉瓣置换术（TAVR）在中危手术风险的严重症状性主动脉瓣狭窄患者中的批准，TAVR 数量预计将在美国呈指数级增长。TAVR 的 30 天再入院率最近报道为 17.9%。机构 TAVR 数量与 30 天再入院指标之间的关联尚未被研究。
目的：评估医院 TAVR 数量与 30 天再入院率之间的关系。
设计、地点和参与者：在这项观察性研究中，我们使用了 2014 年全国再入院数据库来确定有既定 TAVR 计划的医院（在 2014 年第一季度至少进行了 5 次 TAVR）。根据每年的 TAVR 数量，医院被分为低（<50）、中（≥50 至<100）和高（≥100）量。比较低、中、高容量医院 30 天再入院率、原因和费用。数据分析于 2016 年 11 月至 12 月进行。
暴露：经导管主动脉瓣置换术。
主要结果和测量：30 天再入院。
结果：在本研究中纳入的 129 家医院中，20 家（15.5%）为低容量，47 家（36.4%）为中容量，62 家（48.1%）为高容量。在 16252 例指数 TAVR 手术中，分别有 663（4.1%）、3067（18.9%）和 12522（77.0%）在低、中、高容量医院进行。与中容量（调整优势比，0.76；95%置信区间，0.68-0.85；P<0.001）和低容量（调整优势比，0.75；95%置信区间，0.60-0.92；P=0.007）医院相比，高容量医院的 30 天再入院率显著降低。低容量医院的非心脏再入院率更高（65.6%比高容量医院的 60.6%），而高容量医院的心脏再入院率更高（39.4%比低容量医院的 34.4%）。三组之间的住院时间和每次再入院的费用无显著差异（平均[标准差]，5.5[5.0]天比 5.9[7.5]天比 6.0[5.8]天；P=0.74，和 13886 美元[18333 美元]比 14135 美元[17939 美元]比 13432 美元[15725 美元]；P=0.63）。
结论和相关性：据我们所知，这是首次报告医院 TAVR 数量与 30 天再入院率之间存在反比关系。高容量医院的再入院率较低与医疗系统成本显著降低有关。
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