University of Michigan, Ann Arbor, Michigan, USA.
University of Michigan, Ann Arbor, Michigan, USA.
JACC Cardiovasc Interv. 2023 Jan 23;16(2):168-176. doi: 10.1016/j.jcin.2022.10.020.
The 30-day rate of stroke after transcatheter aortic valve replacement (TAVR) has been suggested as a hospital quality metric. Thirty-day stroke rates for nonsurgical, high, and moderate-risk TAVR trials were 3.4% to 6.1%, whereas those in the national Transcatheter Valve Therapy (TVT) Registry for the same patient population were much lower. Hospital comprehensive stroke center (CSC) is the highest designation for integrated acute stroke recognition, management, and care.
Using Michigan TVT data, we assessed whether in-hospital post-TAVR stroke rates varied between CSC and non-CSC institutions.
TVT data submitted from the 22 Michigan Transcatheter Aortic Valve Replacement Collaborative participating institutions between January 1, 2016, and June 30, 2019, were included (N = 6,231). Bayesian hierarchical regression models accounting for patient clinical characteristics and hospital clustering were fitted to assess the association between hospital CSC accreditation and in-hospital post-TAVR stroke. Adjusted ORs and 95% credible intervals were estimated. The University of Michigan Institutional Review Board has waived the need for the approval of studies based on the data collected by the Blue Cross Blue Shield of Michigan Cardiovascular Consortium registry.
There were 3,882 (62.3%) patients at 9 CSC sites and 2,349 (37.7%) patients at 13 non-CSC sites. CSC sites had significantly higher rates of in-hospital post-TAVR stroke (CSC: 2.65% vs non-CSC: 1.15%; P < 0.001). After adjustment, patients who underwent TAVR at a CSC hospital had a significantly higher risk of in-hospital stroke (adjusted OR: 2.21; 95% CI: 1.03-4.62). However, CSC designation was not significantly associated with other important post-TAVR clinical outcomes including 30-day mortality.
Reported Michigan Transcatheter Aortic Valve Replacement Collaborative TVT stroke rates were significantly higher at sites with Joint Hospital Commission stroke designation status; however, other reported important clinical outcomes did not differ significantly based on this designation. CSC designation is a possible factor in stroke rate detection differences between TAVR institutions and might be a factor in the observed differences in stroke rates between TAVR trials and those reported in TVT. In addition, these data suggest that comparison between hospitals based on post-TAVR stroke rates is potentially problematic.
经导管主动脉瓣置换术（TAVR）后的 30 天卒中发生率已被认为是医院质量指标。非手术、高风险和中风险 TAVR 试验的 30 天卒中发生率为 3.4%至 6.1%，而同一患者人群的国家经导管瓣膜治疗（TVT）登记处的卒中发生率要低得多。综合卒中中心（CSC）是识别、管理和治疗急性卒中的最高指定中心。
利用密歇根州 TVT 数据，我们评估了 CSC 和非 CSC 机构之间 TAVR 后院内卒中发生率是否存在差异。
纳入 2016 年 1 月 1 日至 2019 年 6 月 30 日期间，密歇根州 22 家经导管主动脉瓣置换协作参与机构提交的 TVT 数据（N=6231）。使用贝叶斯层次回归模型，根据患者的临床特征和医院聚类情况进行拟合，以评估医院 CSC 认证与 TAVR 后院内卒中之间的关联。估计了调整后的比值比和 95%可信区间。密歇根大学机构审查委员会已根据蓝十字蓝盾密歇根州心血管联合会登记处收集的数据豁免了对研究的批准。
9 家 CSC 医院有 3882 名（62.3%）患者，13 家非 CSC 医院有 2349 名（37.7%）患者。CSC 医院的院内 TAVR 后卒中发生率明显较高（CSC：2.65% vs 非 CSC：1.15%；P<0.001）。调整后，在 CSC 医院接受 TAVR 的患者院内卒中风险显著升高（调整比值比：2.21；95%可信区间：1.03-4.62）。然而，CSC 认定与其他重要的 TAVR 临床结局（包括 30 天死亡率）无显著相关性。
密歇根州经导管主动脉瓣置换协作 TVT 报告的卒中发生率在具有联合医院委员会卒中指定地位的机构中明显较高；然而，基于这一指定，其他报告的重要临床结局并没有显著差异。CSC 认定可能是 TAVR 机构间卒中率检测差异的一个因素，也可能是 TAVR 试验报告的卒中率与 TVT 登记处报告的卒中率之间观察到的差异的一个因素。此外，这些数据表明，基于 TAVR 后卒中率对医院进行比较可能存在问题。
