乌鸦传媒

NEW ORLEANS -- The more transcatheter aortic valve replacements (TAVRs) performed by a center in a year, the less likely it was for patients to have to go back to the hospital, researchers found.

Among U.S. hospitals offering TAVR, the overall rate of 30-day readmits was 16.4%, with a median 9 days to readmission after the procedure. Broken down, readmissions for low-, medium-, and high-volume centers were at 19.5%, 19.0%, and 15.6%, respectively, reported J. Dawn Abbott, MD, of Warren Alpert Medical School of Brown University in Providence, R.I., and colleagues.

On adjustment, readmissions were compared with medium-volume (OR 0.76, 95% CI 0.68-0.85) and low-volume hospitals (OR 0.75, 95% CI 0.60-0.92). Low- and medium-volume centers performed similarly in this regard, they said in a presentation at the Society for Cardiovascular Angiography and Interventions annual meeting. The study was simultaneously published online in JAMA Cardiology.

"We report for the first time, to our knowledge, an inverse association between hospital TAVR volume and 30-day readmissions," according to Abbott's group.

Types of readmission differed numerically: low-volume hospitals took more noncardiac readmits (65.6% versus 60.6% for high-volume ones), while more readmissions at high-volume centers were cardiac-related (39.4% versus 34.4% for low-volume ones).

Length of stay and cost per readmission were stable across the hospitals studied.

"Although our data are hypothesis generating, they do not provide sufficient argument to advocate for regionalization of TAVR care in the United States as TAVR is a maturing field. The procedure was evolving at the time of data acquisition," the authors said. "There is a learning curve for all new procedures and lower-volume hospitals in 2014 that may have been on the learning curve could now represent the high-volume hospitals."

"Currently, there are more than 500 US TAVR hospitals, a more than threefold increase since 2012," commented JAMA Cardiology editor Patrick T. O'Gara, MD, of Brigham and Women's Hospital in Boston.

"The cumulative experience with TAVR is now robust enough to carefully examine not only survival and functional outcomes, but also the processes of care and measures of efficiency and quality that define best practices," he wrote in an .

"It is inevitable that the conversation will turn to questions such as whether there are too many, too few, or just the right number of individual hospitals and whether alternative models of integrated care across hospitals should be considered, especially as the field of transcatheter therapies continues to evolve."

Abbott's group performed an observational analysis of records from the 2014 Nationwide Readmissions Database. Included were 129 hospitals stratified according to annual volume: 15.5% low (<50 TAVR cases), 36.4% medium (50-99), and 48.1% high (>100).

Limiting their analysis were the use of an administrative database that missed readmissions across states and the potential presence of residual confounders even after adjustment.

In addition, said John D. Carroll, MD, of University of Colorado Denver, the authors used "a database that does not include other key factors including socioeconomic status, frailty, and patient-report[ed] health status."

"The root causes for readmissions cannot be gleaned from these data and therefore it is unclear which readmissions are preventable and by what strategies," he wrote in an . "While it is reasonable to hold TAVR sites accountable for the quality of care and the TVT Registry provides a risk-adjusted outcome with national benchmarks, this cannot presently be said for the complex outcome of readmission."

"And rather than consider draconian measures, such as low-volume sites should be closed or payment should be linked to readmission rates, the current time is appropriate for action with standard quality assessment and improvement processes at all TAVR sites," Carroll urged.