Applicability of Transcatheter Aortic Valve Replacement Trials to Real-World Clinical Practice: Findings From EXTEND-CoreValve

Validation of Medicare Advantage Claims for Long-Term Outcome Assessment in Low-Risk Aortic Valve Replacement

BACKGROUND

Although Medicare Advantage (MA) plans provide coverage to >50% of Medicare beneficiaries, it is unclear whether MA claims can be used similarly to Medicare Fee-For-Service (FFS) claims for clinical outcomes assessment. In this study, we evaluate the accuracy of claims algorithms previously validated in FFS to assess comorbidities and outcomes in MA patients after aortic valve replacement.

METHODS

We compared the concordance of 11 claims-based covariates (diabetes, hypertension, atrial flutter/fibrillation, myocardial infarction) and outcomes (stroke, disabling stroke, transient ischemic attack, major vascular complication, bleeding, permanent pacemaker implantation, death) among FFS and MA patients with the covariates and adjudicated outcomes in the multinational Evolut Low-Risk Trial (2016-2018). We used claims algorithms for 1-year outcomes and calculated sensitivity, specificity, positive predictive value, negative predictive value, and kappa, using adjudicated outcomes as the reference. We compared the kappa for MA versus FFS using the 2-sample z-test with a significance level of P<0.05.

RESULTS

Among 1139 US patients aged 65+ years old in the Evolut Low-Risk Trial, 782 patients (175 MA and 607 FFS) were linked to claims data and had complete comorbidity data. Among all covariates, claims algorithms for covariates had sensitivities ≥85% for identifying diabetes, atrial flutter/fibrillation, and hypertension in MA and FFS. For the outcomes, sensitivities were ≥85% for bleeding (comprehensive), permanent pacemaker implantation, and death. The kappa was higher in MA versus FFS for diabetes (P=0.03) and hypertension (P=0.025) but was lower in myocardial infarction (P<0.0001). There was no statistically significant difference in the kappa agreement between MA versus FFS for any of the selected outcomes.

CONCLUSIONS

Medicare claims have a similar level of kappa agreement in MA versus FFS for most covariates and outcomes. As patients shift to MA, ascertainment of outcomes using Medicare claims in postapproval studies remains valid for select outcomes.

SPRINT Treatment Among Adults With Chronic Kidney Disease From 2 Large Health Care Systems

Importance

It is unclear whether the effects of intensive vs standard blood pressure (BP) targets seen in clinical trials generalize to patients with chronic kidney disease (CKD) encountered in everyday practice due to differences in the distribution of cardiovascular risk factors and coexisting conditions.

Objective

To evaluate whether the beneficial and adverse effects of intensive vs standard BP control observed in the Systolic Blood Pressure Intervention Trial (SPRINT) are transportable to a target population of adults with CKD in clinical practice.

Design, Setting, and Participants

This comparative effectiveness study identified 2 populations with CKD who met the eligibility criteria for SPRINT between January 1 and December 31, 2019, in the Veterans Health Administration (VHA) and Kaiser Permanente of Southern California (KPSC). Baseline covariate, treatment, and outcome data from SPRINT were combined with covariate data from these populations to estimate the treatment effects in the target population, applying models that estimated outcomes using distributions in the trial. Analysis was performed between May 2023 and October 2024.

Main Outcomes and Measures

The main outcomes were major cardiovascular events, all-cause death, cognitive impairment, CKD progression, and adverse events at 4 years.

Results

A total of 85 938 patients (mean [SD] age, 75.7 [10.0] years; 81 628 [95.0%] male) from the VHA and 13 983 patients (mean [SD] age, 77.4 [9.6] years; 5371 [38.4%] male) from KPSC were included. Compared with 9361 SPRINT participants (mean [SD] age, 67.9 [9.4] years; 6029 [64.4%] male), these patients were older, had less prevalent cardiovascular disease, higher albuminuria, and used more statins. The associations of intensive vs standard BP control with major cardiovascular events, all-cause death, and adverse events were transportable from the trial to the VHA and KPSC populations; however, the trial's effects on cognitive and CKD outcomes were not transportable in 1 or both clinical populations. Intensive vs standard BP treatment was associated with lower absolute risks for major cardiovascular events at 4 years by 5.1% (95% CI, -9.8% to 3.2%) in the VHA population and 3.0% (95% CI, -6.3% to 0.3%) in the KPSC population and higher risks for adverse events by 1.3% (95% CI, -5.5% to 7.7%) in the VHA population and 3.1% (95% CI, -1.5% to 8.3%) in the KPSC population.

Conclusions and Relevance

In this comparative effectiveness study, the reduction in fatal and nonfatal cardiovascular end points and the increase in adverse events observed in SPRINT were largely transportable to trial-eligible CKD populations from clinical practice, suggesting benefits of implementing intensive BP targets.

Enriching the American Heart Association COVID-19 Cardiovascular Disease Registry Through Linkage With External Data Sources: Rationale and Design

Background The AHA Registry (American Heart Association COVID-19 Cardiovascular Disease Registry) captures detailed information on hospitalized patients with COVID-19. The registry, however, does not capture information on social determinants of health or long-term outcomes. Here we describe the linkage of the AHA Registry with external data sources, including fee-for-service (FFS) Medicare claims, to fill these gaps and assess the representativeness of linked registry patients to the broader Medicare FFS population hospitalized with COVID-19. Methods and Results We linked AHA Registry records of adults ≥65 years from March 2020 to September 2021 with Medicare FFS claims using a deterministic linkage algorithm and with the American Hospital Association Annual Survey, Rural Urban Commuting Area codes, and the Social Vulnerability Index using hospital and geographic identifiers. We compared linked individuals with unlinked FFS beneficiaries hospitalized with COVID-19 to assess the representativeness of the AHA Registry. A total of 10 010 (47.0%) records in the AHA Registry were successfully linked to FFS Medicare claims. Linked and unlinked FFS beneficiaries were similar with respect to mean age (78.1 versus 77.9, absolute standardized difference [ASD] 0.03); female sex (48.3% versus 50.2%, ASD 0.04); Black race (15.1% versus 12.0%, ASD 0.09); dual-eligibility status (26.1% versus 23.2%, ASD 0.07); and comorbidity burden. Linked patients were more likely to live in the northeastern United States (35.7% versus 18.2%, ASD 0.40) and urban/metropolitan areas (83.9% versus 76.8%, ASD 0.18). There were also differences in hospital-level characteristics between cohorts. However, in-hospital outcomes were similar (mortality, 23.3% versus 20.1%, ASD 0.08; home discharge, 45.5% versus 50.7%, ASD 0.10; skilled nursing facility discharge, 24.4% versus 22.2%, ASD 0.05). Conclusions Linkage of the AHA Registry with external data sources such as Medicare FFS claims creates a unique and generalizable resource to evaluate long-term health outcomes after COVID-19 hospitalization.

Association Between Peripheral Versus Central Access for Alternative Access Transcatheter Aortic Valve Replacement and Mortality and Stroke: A Report From the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry

BACKGROUND

In some patients, the alternative access route for transcatheter aortic valve replacement (TAVR) is utilized because the conventional transfemoral approach is not felt to be either feasible or optimal. However, accurate prognostication of patient risks is not well established. This study examines the associations between peripheral (transsubclavian/transaxillary, and transcarotid) versus central access (transapical and transaortic) in alternative access TAVR and 30-day and 1-year end points of mortality and stroke for all valve platforms.

METHODS

Using data from The Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry with linkage to Medicare claims, patients who underwent alternative access TAVR from June 1, 2015 to June 30, 2018 were identified. Adjusted and unadjusted Cox proportional hazards modeling were performed to determine the association between alternate access TAVR site and 30-day and 1-year end points of mortality and stroke.

RESULTS

Of 7187 alternative access TAVR patients, 3725 (52%) had peripheral access and 3462 (48%) had central access. All-cause mortality was significantly lower in peripheral access versus central access group at in-hospital and 1 year (2.9% versus 6.3% and 20.3% versus 26.6%, respectively), but stroke rates were higher (5.0% versus 2.8% and 7.3% versus 5.5%, respectively; all P<0.001). These results persisted after 1-year adjustment (death adjusted hazard ratio, 0.72 [95% CI, 0.62-0.85] and stroke adjusted hazard ratio, 2.92 [95% CI, 2.21-3.85]). When broken down by individual subtypes, compared with transaxillary/subclavian access patients, transapical, and transaortic access patients had higher all-cause mortality but less stroke (P<0.05).

CONCLUSIONS

In this real-world, contemporary, nationally representative benchmarking study of alternate access TAVR sites, peripheral access was associated with favorable mortality and morbidity outcomes compared with central access, at the expense of higher stroke. These findings may allow for accurate prognostication of risk for patient counseling and decision-making for the heart team with regard to alternative access TAVR.