Outcomes, Readmissions and Costs in Transfemoral and Alterative Access Transcatheter Aortic Valve Replacement in the U.S. Medicare Population

• Published in: The Journal of thoracic and cardiovascular surgery Vol. 154; no. 4; pp. 1224 - 1232.e1
• Main Authors: McCarthy, Fenton H., MD, MS, Spragan, Danielle D., MD, Savino, Danielle, BS, Dibble, Taylor, BS, Hoedt, Ashley C., BS, MS, McDermott, Katherine M., BS, Bavaria, Joseph E., MD, Herrmann, Howard C., MD, Anwaruddin, Saif, MD, Giri, Jay, MD, Szeto, Wilson Y., MD, Groeneveld, Peter W., MD, MS, Desai, Nimesh D., MD, PhD
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.10.2017
• Subjects: Aged; Aged, 80 and over; alternative access; Aorta - surgery; Aortic Valve Stenosis - economics; Aortic Valve Stenosis - mortality; Aortic Valve Stenosis - surgery; Cardiothoracic Surgery; Catheterization, Peripheral - methods; Catheterization, Peripheral - statistics & numerical data; cost; Costs and Cost Analysis; Female; Femoral Artery - surgery; Humans; Male; Medicare - economics; Medicare - statistics & numerical data; Outcome and Process Assessment (Health Care); Retrospective Studies; Risk Assessment; Risk Factors; Survival Analysis; TAVR; transapical; Transcatheter Aortic Valve Replacement - adverse effects; Transcatheter Aortic Valve Replacement - economics; Transcatheter Aortic Valve Replacement - methods; Transcatheter Aortic Valve Replacement - statistics & numerical data; transfemoral; Treatment Outcome; United States - epidemiology; United States; transaortic replacement; TAO; MEDPAR; CMS; diagnosis related group; SAVR; TA; TAVR; transapical; transcatheter aortic valve; TF; transfemoral; Medicare Provider Analysis and Review; DRG; ICU; intensive care unit; surgical aortic valve replacement; Center for Medicare and Medicaid Services; cost; OR; CI; HR; IQR; ICD-9; CPB; alternative access
• ISSN: 0022-5223; 1097-685X
• DOI: 10.1016/j.jtcvs.2017.04.090

Abstract Objective Utilization, outcomes and, particularly, cost between transfemoral (TF), transapical (TA) and transaortic (TAO) transcatheter aortic valve replacement (TAVR) patients have yet to be comprehensively evaluated. Methods All Medicare fee-for-service patients undergoing TF (n=4065), TA (n=691), or TAO (n=274) TAVR between January 1, 2011 and November 30, 2012 were identified using Health Care Procedure Classification Codes present on Medicare claims. Hospital charges from Medicare claims were converted to costs using hospital-specific Medicare cost-to-charge ratios. Results TA and TAO patients were similar in age, race, and common comorbidities. Compared to TF patients, TA and TAO patients were more likely to be female and to have peripheral vascular disease, chronic lung disease, and renal failure. Thirty-day mortality rates were higher among TA and TAO patients than among TF patients (TA=9.6%, TAO=8.0%, TF=5.0%, p <0.001). Adjusted mortality beyond 1 year did not differ by access. TA patients were more likely to require cardiopulmonary bypass (CPB). Increased adjusted mortality was associated with CPB (HR 2.13, p<0.01) and increased 30 day cost ($62,000 IQR $45,100 - $86,400 v $48,800 IQR $38,100 - $62,900, p < 0.01). Cost at 30 days was lowest for TF ($48,600) compared to TA ($49,800, p < 0.01) and TAO ($53,200, p = 0.03). Conclusion For patients ineligible to receive TF TAVR, TAO and TA approaches offer similar clinical outcomes at similar cost with acceptable operative- and one-year survival, except higher rates of cardiopulmonary bypass use in TA patients. CPB was associated with worse survival and increased costs.