Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada; Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA.
Can J Cardiol. 2023 May;39(5):570-577. doi: 10.1016/j.cjca.2023.01.025. Epub 2023 Feb 2.
Transcatheter aortic valve replacement (TAVR) has become the standard of care for a wide spectrum of patients with severe aortic stenosis. However, there are wide variations in access to TAVR among jurisdictions. It is unknown if such variation is associated with differences in postprocedural outcomes. Our objective was to determine whether differences in health care delivery in jurisdictions with high vs low access of care to TAVR translate to differences in postprocedural outcomes.
In this observational, retrospective cohort study, we identified all Ontario and New York State residents greater than 18 years of age who received TAVR from January 1, 2012, to December 31, 2018. Our primary outcomes were post-TAVR 30 day in-hospital mortality and all-cause readmissions. Using indirect standardization, we calculated the observed vs expected outcomes for New York patients, had they been treated in Ontario.
Our cohort consisted of 16,814 TAVR patients at 36 hospitals in New York State and 5007 TAVR patients at 11 hospitals in Ontario. In Ontario, TAVR access rates increased from ∼18.2 TAVR per million in 2012 to 87.4 TAVR per million in 2018, whereas for New York State, the rates increased from 31.9 to 220.4 TAVR per million. For 30-day mortality, 3.1% of Ontario TAVR patients had an in-hospital death, compared with 2.5% of New York patients. With adjustment, this translated to an observed-expected ratio of 0.70 (95% confidence interval [CI], 0.54-0.92) for New York patients.
Having greater access to TAVR may be associated with improved outcomes, potentially because of intervention earlier in the trajectory of the disease.
经导管主动脉瓣置换术（TAVR）已成为广泛的严重主动脉瓣狭窄患者的标准治疗方法。然而，在不同司法管辖区之间，TAVR 的可及性差异很大。尚不清楚这种差异是否与术后结果的差异有关。我们的目的是确定在 TAVR 可及性高与低的司法管辖区之间，医疗服务提供方面的差异是否转化为术后结果的差异。
在这项观察性、回顾性队列研究中，我们确定了所有在 2012 年 1 月 1 日至 2018 年 12 月 31 日期间接受 TAVR 的安大略省和纽约州的 18 岁以上居民。我们的主要结局是 TAVR 术后 30 天住院内死亡率和全因再入院率。使用间接标准化，我们计算了如果纽约州患者在安大略省接受治疗，他们的预期与实际结局。
我们的队列包括 36 家纽约州医院的 16814 例 TAVR 患者和 11 家安大略省医院的 5007 例 TAVR 患者。在安大略省，TAVR 的可及性从 2012 年的每百万人约 18.2 例增加到 2018 年的每百万人 87.4 例，而纽约州的 TAVR 每百万人从 31.9 例增加到 220.4 例。在 30 天死亡率方面，安大略省的 3.1%的 TAVR 患者有院内死亡，而纽约州的 2.5%。经调整后，这相当于纽约州患者的观察到的预期比值为 0.70（95%置信区间[CI]，0.54-0.92）。
更大的 TAVR 可及性可能与改善的结局相关，这可能是因为在疾病进程中更早地进行了干预。
