Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, Toronto, Ontario, Canada.
Open Heart. 2022 Jan;9(1). doi: 10.1136/openhrt-2021-001881.
To understand the patient and hospital level drivers of the variation in surgical versus trascatheter aortic valve replacement (SAVR vs TAVR) for patients with aortic stenosis (AS) and to explore whether this variation translates into differences in clinical outcomes.
Adoption of TAVR has grown exponentially worldwide. Notwithstanding, a wide variation in TAVR rates has been seen within and between countries and in some jurisdictions AS is still primarily being managed by SAVR.
We conducted a population-based retrospective cohort study in Ontario, Canada, including individuals who received TAVR or SAVR between 2016 and 2020. We developed iterative hierarchical logistic regression models for the likelihood of receiving TAVR instead of SAVR examining sequentially patient characteristics, hospital factors and year of procedure, calculating the median ORs and variance partition coefficients for each. Using Cox proportional hazards models, we examined the relationship between TAVR/SAVR ratio on all-cause mortality and readmissions.
Annual procedures rates per million population increased from 171 to 201, mainly driven by the expansion of TAVR. TAVR/SAVR ratios differed substantially between hospitals, from 0.21 to 3.27. Neither patient nor hospital factors explained the between-hospital variation in AS treatment. The TAVR/SAVR ratio was significantly associated with clinical outcomes with high ratio hospitals having lower mortality and rehospitalisations.
Despite the expansion of TAVR, dramatic variation exists that is not explained by patient or hospital factors. This variation was associated with differences in clinical outcomes, suggesting that further work is needed in understanding and addressing inequity of access.
了解患者和医院层面导致主动脉瓣狭窄患者接受主动脉瓣置换术（SAVR 与 TAVR）的差异的驱动因素，并探讨这种差异是否转化为临床结果的差异。
经导管主动脉瓣置换术（TAVR）在全球范围内呈指数级增长。尽管如此，在国家内部和国家之间，以及在一些司法管辖区，TAVR 率仍存在很大差异，在某些司法管辖区，主动脉瓣狭窄仍主要通过 SAVR 治疗。
我们在加拿大安大略省进行了一项基于人群的回顾性队列研究，纳入了 2016 年至 2020 年间接受 TAVR 或 SAVR 的患者。我们为接受 TAVR 而不是 SAVR 的可能性开发了迭代分层逻辑回归模型，依次检查患者特征、医院因素和手术年份，计算每个因素的中位数 OR 和方差分解系数。使用 Cox 比例风险模型，我们检查了 TAVR/SAVR 比值与全因死亡率和再入院之间的关系。
每百万人口的年手术量从 171 例增加到 201 例，主要是由于 TAVR 的扩张。医院之间的 TAVR/SAVR 比值差异很大，从 0.21 到 3.27。患者和医院因素均不能解释 AS 治疗的医院间差异。TAVR/SAVR 比值与临床结果显著相关，比值高的医院死亡率和再入院率较低。
尽管 TAVR 有所扩展，但仍存在很大差异，且无法用患者或医院因素来解释。这种差异与临床结果的差异有关，这表明需要进一步努力了解和解决获得途径的不平等问题。
