Thirty-Day Readmissions After Transcatheter Aortic Valve Implantation Versus Surgical Aortic Valve Replacement in Patients With Severe Aortic Stenosis in New York State

Burden of hospitalization during the first year following transcatheter and surgical aortic valve replacement

BACKGROUND

Hospitalizations are a major burden for both patients and society but are potentially preventable. We examined the one-year hospitalization burden in patients undergoing transcatheter aortic valve replacement (TAVR) and compared hospitalization rates and patterns with those undergoing isolated surgical aortic valve replacement (SAVR).

METHODS

Using Danish nationwide registries, we identified patients who underwent first-time TAVR and isolated SAVR (2008-2019), respectively. Subsequent hospitalizations were classified as cardiovascular or noncardiovascular according to discharge diagnosis codes.

RESULTS

Patients undergoing TAVR (N = 4,921) were older and had more comorbidities than those undergoing SAVR (N = 5,220). There were 5,725 and 4,426 hospitalizations within the first year after discharge in the TAVR and SAVR group, respectively. During the one-year follow-up period post-TAVR, 46.6% were not admitted, 25.4% were admitted once, 12.6% twice, and 15.4% 3 times or more. The corresponding proportions in patients undergoing SAVR were 55.3%, 25.1%, 10.0%, and 9.5%, respectively. Among patients with ≥1 hospitalization following TAVR, 50.3% had a total length of all hospital stays between 1 and 7days, 19.0% 8-14days, 18.0% 15-30days, 9.9% 31-60days, and 2.8% ≥61days. The corresponding proportions for patients undergoing SAVR were 58.6%, 17.2%, 13.1%, 7.4%, and 3.7%, respectively. Compared with patients undergoing SAVR, those undergoing TAVR had a lower early (day0-30: HR 0.89 [95% CI, 0.80-0.98]), but a higher late hospitalization rate (day 31-365: 1.46 [1.32-1.60]).

CONCLUSIONS

The 1-year hospitalization burden following TAVR is substantial. Compared with patients undergoing isolated SAVR, those undergoing TAVR had a lower early, but a higher late hospitalization rate - a difference that likely reflects unmeasured differences in the patient cohorts.

Same-Day Discharge After Transcatheter Aortic Valve Implantation: Insights from the Nationwide Readmission Database 2015 to 2019

Background There is a paucity of data on the feasibility of same-day discharge (SDD) following transcatheter aortic valve implantation (TAVI) at a national level. Methods and Results This study used data from the Nationwide Readmission Database from the fourth quarter of 2015 through 2019 and identified patients undergoing TAVI using the claim code 02RF3. A total of 158 591 weighted hospitalizations for TAVI were included in the analysis. Of the patients undergoing TAVI, 961 (0.6%) experienced SDD. Non-SDDs included 65 814 (41.5%) patients who underwent TAVI who were discharged the next day, and 91 816 (57.9%) discharged on the second or third day. The 30-day readmission rate for SDD after TAVI was similar to non-SDD TAVI (9.8% versus 8.9%, P=0.31). The cumulative incidence of 30-day readmissions for SDD was higher compared with next-day discharge (log-rank P=0.01) but comparable to second- or third-day discharge (log-rank P=0.66). At 30 days, no differences were observed in major or minor vascular complications, heart failure, or ischemic stroke for SDD compared with non-SDD. Acute kidney injury, pacemaker implantation, and bleeding complications were lower with SDD. Predictors associated with SDD included age <85 years, male sex, and prior pacemaker placement, whereas left bundle-branch block, right bundle-branch block, second-degree heart block, heart failure, prior percutaneous coronary intervention, and atrial fibrillation were negatively associated with SDD. Conclusions SDD following TAVI is associated with similar 30-day readmission and complication rates compared with non-SDD. Further prospective studies are needed to assess the safety and feasibility of SDD after TAVI.

Center Variability in Medicare Claims-Based Publicly Reported Transcatheter Aortic Valve Replacement Outcome Measures

Background

Public reporting of transcatheter aortic valve replacement (TAVR) claims–based outcome measures is used to identify high‐ and low‐performing centers. Whether claims‐based TAVR outcomes can reliably be used for center‐level comparisons is unknown. In this study, we sought to evaluate center variability in claims‐based TAVR outcomes used in public reporting.

Methods and Results

The study sample included 119 554 Medicare beneficiaries undergoing TAVR between January 2014 and October 2018 based on procedure codes in 100% Medicare inpatient claims. Multivariable hierarchical logistic regression was used to estimate center‐specific adjusted rates and reliability (R) of 30‐day mortality, discharge not to home/self‐care, 30‐day stroke, and 30‐day readmission. Reliability was defined as the ratio of between‐hospital variation to the sum of the between‐ and within‐hospital variation. The median (interquartile range [IQR]) center‐level adjusted outcome rates were 3.1% (2.9%–3.4%) for 30‐day mortality, 41.4% (31.3%–53.4%) for discharge not to home, 2.5% (2.3%–2.7%) for 30‐day stroke, and 14.9% (14.4%–15.5%) for 30‐day readmission. Median reliability was highest for the discharge not to home measure (R=0.95; IQR, 0.94–0.97), followed by the 30‐day stroke (R=0.92; IQR, 0.87–0.94), 30‐day mortality (R=0.86; IQR, 0.81–0.91), and 30‐day readmission measures (R=0.42; IQR, 0.35–0.51). Across outcomes, there was an inverse relationship between center volume and measure reliability.

Conclusions

Claims‐based TAVR outcome measures for mortality, discharge not to home, and stroke were reliable measures for center‐level comparisons, but readmission measures were unreliable. Stakeholders should consider these findings when evaluating claims‐based measures to compare center‐level TAVR performance.

Real-life outcomes and readmissions after a TAVI procedure in a Glasgow population

Transcatheter aortic valve implantation (TAVI) is a routine procedure for patients with symptomatic severe aortic stenosis who are deemed inoperable or high-risk surgical candidates. The aim of this study was to examine real-world data on death and readmission rates in patients following the procedure. Electronic health records for patients who underwent TAVI between April 2015 and November 2018 were reviewed. Details of the procedure, complications, length of initial hospital stay and outcomes of interest (subsequent admissions and mortality) were recorded. In our cohort of 124 patients, the mean age was 80.8 years and 43% were male. Cardiac comorbidities were common, more than 30% had myocardial infarction (MI) and 15% had a previous coronary artery bypass graft (CABG). One in five suffered from chronic obstructive pulmonary disease (COPD), with similar prevalence of diabetes mellitus and cerebrovascular accident (CVA). In-hospital mortality was low at 3.3%, however, 30-day readmission rates were high at 14.6%; 44.4% were readmitted to hospital within one year. TAVI is a successful procedure in Scotland with good outcome data. The potential benefit of the procedure in many patients is limited by comorbidities, which shorten life-expectancy and lead to hospital readmission. These data highlight the importance of effective multi-disciplinary discussion in a time of realistic medicine.

Evaluation of the incidence, timing, and potential recovery rates of complete atrioventricular block after transcatheter aortic valve implantation: a Japanese multicenter registry study

Data on the accurate onset date and serial changes of the complete atrioventricular block (CAVB) after transcatheter aortic valve implantation (TAVI) are limited. This study aimed to assess the incidence, timing, and potential recovery of CAVB following TAVI. Total 696 patients who underwent TAVI were enrolled. Acute CAVB was evaluated within 24 h; delayed CAVB was evaluated 24 h after TAVI. Recovered CAVB was defined as ventricular pacing < 1% during the follow-up or transit block without the need for permanent pacemaker implantation (PMI). The other patients with CAVB were categorized as continued CAVB. Clinical differences between the recovered and continued CAVB groups were evaluated, and the predictive factors of continued CAVB were assessed. The incidence rates of CAVB, acute CAVB, and delayed CAVB were 6.9% (48/696), 4.6% (32/696), and 2.3% (16/696), respectively. Overall, 47.9% (23/48) of patients had recovered CAVB, which was more prevalent in the acute CAVB group than in the delayed CAVB group [59.4% (19/32) vs. 25.0% (4/16), p = 0.025]. CAVB recovery occurred within 24 h (61.0%, 14/23) and after 24 h (39.0%, 9/23). Before CAVB recovery, 21.7% (5/23) of patients had already undergone PMI. A pre-existing complete right bundle branch block (CRBBB) was the only independent predictive factor of continued CAVB (odds ratio 4.51, 95% confidence interval 1.03-19.6, p = 0.045). In conclusion, a pre-existing CRBBB and the timing and prolonged duration of CAVB may be used in risk stratification to determine the appropriateness of early discharge, optimal PMI date, and PMI indication.

Causes and characteristics associated with early and late readmission after open-heart valve surgery

OBJECTIVES

The objectives of the study were to describe the causes of readmission from discharge to 30 days and from day 31 to 180 after discharge and to investigate the characteristics associated with overall and cause-specific readmissions after open-heart valve surgery.

METHODS

A single-center, retrospective cohort of 980 patients undergoing open-heart valve surgery from 2013 to 2016. Time to the first readmission was analyzed using univariable and multivariable Cox proportional hazard models. Results are reported as hazard ratios (HR) with 95% confidence intervals (CI).

RESULTS

In total, 366 patients (37%) experienced unplanned cardiac readmission within 180 days after discharge. Within 30 days after discharge, the most frequent causes of readmission were pericardial/pleural effusions (n = 87), infections (n = 50), and atrial fibrillation/flutter (n = 45). Accordingly, infections (n = 32) were the most common cause from day 31 to 180. No powerful predictors of overall cardiac readmission were identified, but several characteristics were associated with cause-specific readmissions: age ≤65 years (HR: 1.85; CI: 1.18-2.88), male gender (HR: 1.85; CI: 1.11-3.09), high alcohol intake (HR: 1.99; CI: 1.22-3.24) and mitral valve procedures (HR: 1.86; CI: 1.11-3.10) were associated with readmissions due to effusions. Ischemic heart disease with a prior percutaneous coronary intervention (HR: 2.94; CI: 1.53-5.63), mitral valve procedures (HR: 2.10; CI: 1.23-3.59), and postoperative atrial fibrillation/flutter (HR: 1.71; CI: 1.03-2.85) were associated with atrial fibrillation/flutter readmissions.

CONCLUSION

Predicting overall readmissions after open-heart valve surgery is difficult as causes of readmissions vary and different causes are associated with different characteristics. Future studies should target reducing cause-specific readmissions.

Causes and predictors of readmission after transcatheter aortic valve implantation : A meta-analysis and systematic review

BACKGROUND

Since readmission rate is an important clinical index to determine the quality of inpatient care and hospital performance, the aim of this study was to explain the causes and predictors of readmission following transcatheter aortic valve implantation (TAVI) at short-term and mid-term follow-up.

METHODS AND RESULTS

A systematic review and meta-analysis of all published articles from Embase, Pubmed/MEDLINE, and Ovid was carried out. In all, 10 studies including 52,702 patients were identified. The pooled estimate for the overall event rate was 0.15, and cardiovascular causes were the main reason for 30-day readmission (0.42, 95% confidence interval [CI]: 0.39-0.45). In addition, the pooled incidence of 1‑year readmission was 0.31, and cardiovascular events were still the main cause (0.41, 95% CI: 0.33-0.48). Patients with major and life-threatening bleeding, new permanent pacemaker implantation, and clinical heart failure were associated with a high risk for early readmission after TAVI. Moreover, an advanced (≥3) New York Heart Association classification, acute kidney injury, paravalvular leak, mitral regurgitation (≥ moderate), and major bleeding predicted unfavorable outcome to 1‑year readmission. Female gender and transfemoral TAVI was associated with a lower risk for unplanned rehospitalization.

CONCLUSIONS

This meta-analysis found cardiovascular factors to be the main causes for both 30-day and 1‑year rehospitalization. Heart failure represented the most common cardiovascular event at both short-term and mid-term follow-up. Several baseline characteristics and procedure-related factors were deemed unfavorable predictors of readmission. Importantly, transfemoral access and female gender were associated with a lower risk of readmission.

Incidence and predictors of readmissions to non-index hospitals after transcatheter aortic valve replacement and the impact on in-hospital outcomes: From the nationwide readmission database

INTRODUCTION

Whether readmission to non-index hospitals (where the initial procedure was not performed) could result in adverse outcomes and increased utilization of healthcare resources compared with readmission to index hospitals after transcatheter aortic valve replacement (TAVR) remains unclear.

METHODS

From January 2012 to September 2015, a nationwide readmission database was queried to identify those who were older than 50 years and had endovascular TAVR, using the International Classification of Disease, 9th Revision, Clinical Modification code 35.05. Elective readmissions were excluded. In-hospital outcomes were compared between the index and non-index hospital readmissions. A multivariable logistic regression analysis was performed to identify predictors of non-index hospital readmissions.

RESULTS

A total of 6808 readmissions were identified of which 2564 (37.7%) were readmitted to non-index hospitals. Residents at smaller counties, metropolitan non-teaching hospitals, or hospitals at large metropolitan areas were predictors of non-index readmissions. In-hospital mortality (adjusted odds ratio [aOR] 1.27, p = 0.20), acute myocardial infarction (aOR 0.83, p = 0.53), pacemaker placement (aOR 0.97, p = 0.90), acute kidney injury (aOR 0.98, p = 0.84), and stroke (aOR 1.03, p = 0.90) were similar between index and non-index readmissions but bleeding events requiring transfusions were more frequently observed in readmissions at non-index hospitals (aOR 1.32, p = 0.025). Hospital cost (15,410 dollars vs. 16,390 dollars, p = 0.25) and length of stay (5.70 days vs. 5.65 days, p = 0.85) were comparable between groups.

CONCLUSIONS

Non-index readmissions post-TAVR was relatively common but did not result in increased hospital mortality or healthcare utilization. Our results are reassuring for TAVR recipients with limited access to index hospitals.

Derivation and external validation of a simple risk tool to predict 30-day hospital readmissions after transcatheter aortic valve replacement

AIMS

Patients undergoing transcatheter aortic valve replacement (TAVR) possess a higher risk of recurrent healthcare resource utilisation due to multiple comorbidities, frailty, and advanced age. We sought to devise a simple tool to identify TAVR patients at increased risk of 30-day readmission.

METHODS AND RESULTS

We used the Nationwide Readmissions Database from January 2013 to September 2015. Complex survey methods and hierarchical regression in R were implemented to create a prediction tool to determine probability of 30-day readmission. Boot-strapped internal validation and cross-validation were performed to assess model accuracy. External validation was performed using a single-centre data set. Of 39,305 patients who underwent endovascular TAVR, 6,380 (16.2%) were readmitted within 30 days. The final 30-day readmission risk prediction tool included the following variables: chronic kidney disease, end-stage renal disease on dialysis (ESRD), anaemia, chronic lung disease, chronic liver disease, atrial fibrillation, length of stay, acute kidney injury, and discharge disposition. ESRD (OR 2.11, 95% CI: 1.7-2.63), length of stay ≥5 days (OR 1.64, 95% CI: 1.50-1.79), and short-term hospital discharge disposition (OR 1.81, 95% CI: 1.2-2.7) were the strongest predictors. The c-statistic of the prediction model was 0.63. The c-statistic in the external validation cohort was 0.69. On internal calibration, the tool was extremely accurate in predicting readmissions up to 25%.

CONCLUSIONS

A simple and easy-to-use risk prediction tool utilising standard clinical parameters identifies TAVR patients at increased risk of 30-day readmission. The tool may consequently inform hospital discharge planning, optimise transitions of care, and reduce resource utilisation.

Profiling Hospital Performance on the Basis of Readmission After Transcatheter Aortic Valve Replacement in Ontario, Canada

Background

Readmission rates are a widely accepted quality indicator. Our objective was to develop models for calculating case‐mixed adjusted readmission rates after transcatheter aortic valve replacement for the purpose of profiling hospitals.

Methods and Results

In this population‐based study in Ontario, Canada, we identified all transcatheter aortic valve replacement procedures between April 1, 2012, and March 31, 2016. For each hospital, we first calculated 30‐day and 1‐year risk‐standardized (predicted versus expected) readmission rates, using 2‐level hierarchical logistic regression models, including clustering of patients within hospitals. We also calculated the risk‐adjusted (observed versus expected) readmission rates, accounting for the competing risk of death using a Fine‐Gray competing risk model. We categorized hospitals into 3 groups: those performing worse than expected, those performing better than expected, or those performing as expected, on the basis of whether the 95% CI was above, below, or included the provincial average readmission rate respectively. Our cohort consisted of 2129 transcatheter aortic valve replacement procedures performed at 10 hospitals. The observed readmission rate was 15.4% at 30 days and 44.2% at 1 year, with a range of 10.9% to 21.7% and 38.8% to 55.0%, respectively, across hospitals. Incorporating the competing risk of death translated into meaningful different results between models; as such, we concluded that the risk‐adjusted readmission rate was the preferred metric. On the basis of the 30‐day risk‐adjusted readmission rate, all hospitals performed as expected, with a 95% CI that included the provincial average. However, we found that there was significant variation in 1‐year risk‐adjusted readmission rate.

Conclusions

There is significant interhospital variation in 1‐year adjusted readmission rates among hospitals, suggesting that this should be a focus for quality improvement efforts in transcatheter aortic valve replacement.

Association Between Hospital Volume and 30-Day Readmissions Following Transcatheter Aortic Valve Replacement

Importance

With the approval of transcatheter aortic valve replacement (TAVR) for patients with severe symptomatic aortic stenosis at intermediate surgical risk, TAVR volume is projected to increase exponentially in the United States. The 30-day readmission rate for TAVR was recently reported at 17.9%. The association between institutional TAVR volume and the 30-day readmission metric has not been examined.

Objective

To assess the association between hospital TAVR volume and 30-day readmission.

Design, Setting, and Participants

In this observational study, we used the 2014 Nationwide Readmissions Database to identify hospitals with established TAVR programs (performing at least 5 TAVRs in the first quarter of 2014). Based on annual TAVR volume, hospitals were classified as low (<50), medium (≥50 to <100), and high (≥100) volume. Rates, causes, and costs of 30-day readmissions were compared between low-, medium-, and high-volume hospitals. Data were analyzed from November to December 2016.

Exposure

Transcatheter aortic valve replacement.

Main Outcomes and Measures

Thirty-day readmissions.

Results

Of 129 hospitals included in this study, 20 (15.5%) were categorized as low volume, 47 (36.4%) as medium volume, and 62 (48.1%) as high volume. Of 16 252 index TAVR procedures, 663 (4.1%), 3067 (18.9%), and 12 522 (77.0%) were performed at low-, medium-, and high-volume hospitals, respectively. Thirty-day readmission rates were significantly lower in high-volume compared with medium-volume (adjusted odds ratio, 0.76; 95% CI, 0.68-0.85; P < .001) and low-volume (adjusted odds ratio, 0.75; 95% CI, 0.60-0.92; P = .007) hospitals. Noncardiac readmissions were more common in low-volume hospitals (65.6% vs 60.6% in high-volume hospitals), whereas cardiac readmissions were more common in high-volume hospitals (39.4% vs 34.4% in low-volume hospitals). There were no significant differences in length of stay and costs per readmission among the 3 groups (mean [SD], 5.5 [5.0] days vs 5.9 [7.5] days vs 6.0 [5.8] days; P = .74, and $13 886 [18 333] vs $14 135 [17 939] vs $13 432 [15 725]; P = .63, respectively).

Conclusions and Relevance

We report for the first time, to our knowledge, an inverse association between hospital TAVR volume and 30-day readmissions. Lower readmission at higher-volume hospitals was associated with significantly lower cost to the health care system.

Endovascular Versus Transapical Transcatheter Aortic Valve Replacement: In-hospital Mortality, Hospital Outcomes, and 30-day Readmission. A Propensity Score-matched Analysis

INTRODUCTION

Transapical transcatheter aortic valve replacement (TAVR) is associated with increased morbidity compared with endovascular TAVR. We sought to compare the differences in clinical outcomes between endovascular and transapical TAVR approaches utilizing a propensity score model.

METHODS

Patients undergoing TAVR (International Classification of Diseases, Ninth Revision, Clinical Modification codes 35.05 and 35.06) between January 2011 and November 2014 were identified in the Nationwide Readmissions Database, and a propensity score-matched analysis was performed comparing transapical versus endovascular approach. The primary outcome of interest was in-hospital mortality and 30-day all-cause readmission. We also evaluated trends in use of TAVR over the years.

RESULTS

We identified 28,302 endovascular TAVR and 7967 transapical TAVR performed during the study period. The propensity score-matching algorithm yielded 7879 well-matched patients in each group. The in-hospital mortality rates were significantly lower in endovascular TAVR compared with transapical TAVR (1.7% vs 6.7%; OR, 0.24; 95% CI, 0.17- 0.35; P < 0.001). The 30-day readmission rate was lower in endovascular TAVR (14.4% vs 16.8%; OR, 0.83; 95% CI, 0.70-0.98; P = 0.036). Use of TAVR increased from 585 (74% endovascular TAVR) in 2011 to 16,801 in 2014 (82.8% endovascular TAVR).

CONCLUSIONS

Endovascular TAVR is associated with significantly lower in-patient mortality and lower readmission rate when compared with transapical TAVR. Heart failure remains the most common cause for readmission after TAVR regardless of approach.

Trends in Readmission and Costs After Transcatheter Implantation Versus Surgical Aortic Valve Replacement in Patients With Renal Dysfunction

Patients with renal dysfunction are at increased risk for developing aortic valve pathology. In the present era of value-based healthcare delivery, a comparison of transcatheter and surgical aortic valve replacement (SAVR) readmission performance in this population is warranted. All adult patients who underwent transcatheter or SAVR from 2011 to 2014 were identified using the Nationwide Readmissions Database, containing data for nearly 50% of US hospitalizations. Patients were further stratified as chronic kidney disease stage 1 to 5 as well as end-stage renal disease requiring dialysis. Kaplan-Meier, Cox Hazard, and multivariable regression models were generated to identify predictors of readmission and costs. Of the 350,609 isolated aortic valve replacements, 4.7% of patients suffered from chronic kidney disease stages 1 to 5 or end-stage renal disease. Transcatheter aortic valve patients with chronic kidney disease stages 1 to 5/or end-stage renal disease were older (81.9 vs 72.9 years, p <0.0001) with a higher prevalence of heart failure (15.2 vs 4.3%, p = 0.04), and peripheral vascular disease (31.1 vs 22.8%, p <0.0001) compared to their SAVR counterparts. Transcatheter aortic valve replacement in chronic kidney disease stage 1 to 3 patients had a higher rate of readmission due to heart failure and pacemaker placement than SAVR. Transcatheter aortic valve replacement was associated with increased costs compared with SAVR for all renal failure patients. In conclusion, in this national cohort of chronic and end-stage renal disease patients, transcatheter aortic valve implantation was associated with increased mortality, readmissions for chronic kidney disease stages1 to 3, and index hospitalization costs.

The Relationship Between Heart-Failure Hospitalization and Mortality in Patients Receiving Transcatheter Aortic Valve Replacement

BACKGROUND

Patients who have had transcatheter aortic valve replacement (TAVR) are at risk of hospitalization during the first year postprocedure. Few studies have examined the incidence of heart- failure hospitalizations (HFH) post-TAVR and the impact this has on subsequent hospitalizations and mortality. Our aim was to determine the incidence, predictors, and mortality associated with HFH post-TAVR.

METHODS

We used prospectively collected data for all patients who underwent TAVR between August 1, 2010, and March 31, 2015; 742 consecutive patients who underwent TAVR during the study period were included. Patients were followed for a minimum of 1 year post-TAVR.

RESULTS

Mean age was 80.9 ± 8.1, and 58.2% were men. Hospitalizations post-TAVR occurred in 20% of patients at 30 days and 59.7% at 1 year. Of patients hospitalized, HFH was the primary cause of hospitalization in 25.8% and 21.4% of patients at 30 days and 1 year post-TAVR, respectively. Patients with HFH at either 30 days or 1 year had higher subsequent rates of rehospitalization compared with patients who had non-HFH. Patients with HFH or non-HFH at 30 days had 1-year mortality rates of 23.1% and 21.4%, respectively, whereas those with HFH by 1 year had a higher 1-year rate of mortality compared with patients who had non-HFHs (25% vs 10.9%, P < 0.001).

CONCLUSIONS

HF accounts for a quarter of all hospitalizations post-TAVR and is associated with higher rates of subsequent rehospitalization and death compared with those who had non-HFH. Understanding predictors of readmissions post-TAVR will allow for better risk stratification and improve outcomes in patients receiving TAVR.

Comparison of Causes and Associated Costs of 30-Day Readmission of Transcatheter Implantation Versus Surgical Aortic Valve Replacement in the United States (A National Readmission Database Study)

Our current knowledge about comparative differences in 30-day readmissions and the impact of readmissions on overall costs after transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR) is largely derived from clinical trials. The objectives of this study were to compare readmissions and costs for TAVI and SAVR in a nationally representative population-based sample. The Healthcare Cost and Utilization Project's National Readmission Database was used for the study. Hierarchical multivariable regression analyses were used to examine differences in the propensity score 1:1 matched cohort. The matched cohort included 4,682 patients who survived index procedures done from January through November 2013. Compared with SAVR, the rate of 30-day readmission was not significantly different for endovascular TAVI (16% vs 18%; p = 0.19); and was higher for the transapical TAVI (22% vs 17%; p <0.01) group. The 30-day cumulative costs were higher for the 2 endovascular TAVI ($51,025 vs $46,228; p = 0.03) and transapical TAVI ($59,575 vs $45,792; p <0.01). In multivariable analyses, the risk of 30-day readmission was similar for endovascular TAVI (odds ratio [OR] 0.93; 95% confidence interval [CI] 0.78 to 1.12) and was 27% higher for transapical TAVI (OR 1.27; 95% CI 1.02 to 1.57). Cumulative costs (index plus readmission costs) were 13% (β 0.13; 95% CI 0.10 to 0.15) and 19% (β 0.19; 95% CI 0.16 to 0.23) higher for the endovascular TAVI and transapical TAVI, respectively. In conclusion, the rate of readmissions was similar for endovascular TAVI and SAVR but the costs were 26% higher for TAVI than for SAVR.

Hospital readmission following transcatheter aortic valve implantation in the real world

BACKGROUND

There is limited data on hospital readmissions following transcatheter aortic valve implantation (TAVI). The aim of this study was to investigate hospital readmissions post-TAVI.

METHODS

Data from the Optimized transCathEter vAlvular iNtervention (OCEAN-TAVI) multicenter registry (registration no. UMIN000020423) were collected from 1215 patients who underwent TAVI. Incidence, timing, causes, and predictors of readmission in addition to the impact on patient outcomes were analyzed.

RESULTS

Of 1215 patients, 223 (18.4%) were readmitted within 1 year post-TAVI. Early readmission (≤30 days) occurred in 42 patients, while late readmission (>30 days) occurred in 181 patients. Readmissions were due to cardiac disorders, such as heart failure and arrhythmia, in 77 patients and non-cardiac disorders, such as respiratory disorders, infections, and cerebrovascular events, in 146 patients. Kaplan-Meier analysis revealed that early readmission was associated with a lower 1-year survival compared to non-early readmission (72.4% vs. 89.0%, p < 0.05). Multivariate Cox regression analysis showed that acute kidney injury (hazard ratio [HR], 2.27; p = 0.03) was an independent predictor of early readmission, while anemia (HR, 2.21; p < 0.01), hypoalbuminemia (HR, 1.37; p = 0.04), atrial fibrillation (HR, 1.70; p < 0.01), and more than mild postprocedural aortic regurgitation (HR, 1.62; p < 0.01) were independent predictors of late readmission.

CONCLUSION

Readmission occurred in approximately one-fifth of patients post-TAVI and was associated with poor patient outcomes. Early readmission was mainly due to procedural complications, while late readmission was mainly determined by baseline comorbidities including a frailty criterion. Measures should be taken to reduce hospital readmissions and improve patient outcomes post-TAVI.

Rates and predictors of hospital readmission after transcatheter aortic valve implantation

Aims

To analyse reasons, timing and predictors of hospital readmissions after transcatheter aortic valve implantation (TAVI).

Methods and results

Patients included in the Bern TAVI Registry between August 2007 and June 2014 were analysed. Fine and Gray competing risk regression was used to identify factors predictive of hospital readmission within 1 year after TAVI with bootstrap analysis for internal validation. Of 868 patients alive at discharge, 221 (25.4%) were readmitted within 1 year. Compared with patients not requiring readmission, those with at least one readmission more frequently were male and more often had atrial fibrillation and higher creatinine values (P < 0.05 for all cases). For overall 308 readmissions, cardiovascular causes accounted for 46.1% with heart failure as the most frequent indication; non-cardiovascular readmissions occurred for surgery (11.7%), gastrointestinal disorders (9.7%), malignancy (4.9%), respiratory diseases (4.6%) and chronic kidney failure (2.6%). Male gender (subhazard ratio, SHR, 1.33, 95% confidence intervals, CI, 1.02-1.73, P = 0.035) and stage 3 kidney injury (SHR 2.04, 95% CI 1.12-3.71, P = 0.021) were found independent risk factors for any hospital readmission, whereas previous myocardial infarction (SHR 1.88, 95% CI 1.22-2.90, P = 0.004) and in-hospital life-threatening bleeding (SHR 2.18, 95%CI 1.24-3.85, P = 0.007) were associated with cardiovascular readmissions. The event rate for mortality was significantly increased after readmissions for any cause (RR 4.29, 95% CI 2.86-6.42, P < 0.001).

Conclusion

Hospital readmission was observed in one out of four patients during the first year after TAVI and was associated with a significant increase in mortality.

Effect of Gender on Unplanned Readmissions After Percutaneous Coronary Intervention (from the Nationwide Readmissions Database)

Women who undergo percutaneous coronary intervention (PCI) are at higher risk of adverse outcomes compared with men, but it is unknown whether gender affects early unplanned rehospitalization. We analyzed 832,753 patients who underwent PCI from 2013 to 2014 in the Nationwide Readmissions Database. We compared gender differences in incidences, predictors, causes, and cost of unplanned 30-day readmissions and examined the effect of co-morbidity. A total of 832,753 men and women who survived the index PCI and were not admitted for a planned readmission were included in the analysis. Overall, 9.4% of patients had an unplanned readmission within 30 days. Thirty-day readmission rates were higher in women compared with men (11.5% vs 8.4%, p <0.001) even after multivariate adjustment (odds ratio 1.19, 95% confidence interval 1.16 to 1.22, p <0.001), although women had significantly lower costs associated with the readmission ($11,927 vs $12,758, p <0.001). The cause of readmission for women and men were similar and the majority of the readmissions were due to noncardiac causes (58% vs 55%), the most common of which were nonspecific chest pain, gastrointestinal disease, and infections. In contrast, for cardiac readmissions, women are more likely to be readmitted for heart failure (29.64% vs 22.34%), whereas men are more likely to be readmitted for coronary artery disease, including angina (33.47% vs 28.54%). In conclusion, gender disparities exist in rates of unplanned rehospitalization after PCI, where more than 1 in 10 women who undergo PCI are readmitted within 30 days. Gender differences were not observed for causes of noncardiac readmissions, whereas important differences were observed for cardiovascular causes.

Thirty-Day Readmissions After Transcatheter Aortic Valve Replacement in the United States: Insights From the Nationwide Readmissions Database

BACKGROUND

Readmissions after cardiac procedures are common and contribute to increased healthcare utilization and costs. Data on 30-day readmissions after transcatheter aortic valve replacement (TAVR) are limited.

METHODS AND RESULTS

Patients undergoing TAVR (International Classification of Diseases-Ninth Revision-CM codes 35.05 and 35.06) between January and November 2013 who survived the index hospitalization were identified in the Nationwide Readmissions Database. Incidence, predictors, causes, and costs of 30-day readmissions were analyzed. Of 12 221 TAVR patients, 2188 (17.9%) were readmitted within 30 days. Length of stay >5 days during index hospitalization (hazard ratio [HR], 1.47; 95% confidence interval [CI], 1.24-1.73), acute kidney injury (HR, 1.23; 95% CI, 1.05-1.44), >4 Elixhauser comorbidities (HR, 1.22; 95% CI, 1.03-1.46), transapical TAVR (HR, 1.21; 95% CI, 1.05-1.39), chronic kidney disease (HR, 1.20; 95% CI, 1.04-1.39), chronic lung disease (HR, 1.16; 95% CI, 1.01-1.34), and discharge to skilled nursing facility (HR, 1.16; 95% CI, 1.01-1.34) were independent predictors of 30-day readmission. Readmissions were because of noncardiac causes in 61.8% of cases and because of cardiac causes in 38.2% of cases. Respiratory (14.7%), infections (12.8%), bleeding (7.6%), and peripheral vascular disease (4.3%) were the most common noncardiac causes, whereas heart failure (22.5%) and arrhythmias (6.6%) were the most common cardiac causes of readmission. Median length of stay and cost of readmissions were 4 days (interquartile range, 2-7 days) and $8302 (interquartile range, $5229-16 021), respectively.

CONCLUSIONS

Thirty-day readmissions after TAVR are frequent and are related to baseline comorbidities, TAVR access site, and post-procedure complications. Awareness of these predictors can help identify and target high-risk patients for interventions to reduce readmissions and costs.

Elevation of B-Type Natriuretic Peptide at Discharge is Associated With 2-Year Mortality After Transcatheter Aortic Valve Replacement in Patients With Severe Aortic Stenosis: Insights From a Multicenter Prospective OCEAN-TAVI (Optimized Transcatheter Valvular Intervention-Transcatheter Aortic Valve Implantation) Registry

Background

In this study, we sought to investigate the 2‐year prognostic impact of B‐type natriuretic peptide (BNP) levels at discharge, following transcatheter aortic valve replacement.

Methods and Results

We enrolled 1094 consecutive patients who underwent transcatheter aortic valve replacement between 2013 and 2016. Study patients were stratified into 2 groups according to survival classification and regression tree analysis (high versus low BNP groups). We evaluated the impact of high BNP on 2‐year mortality compared with that of low BNP using a multivariable Cox model, and assessed whether this stratification would improve predictive accuracy for determining 2‐year mortality by assessing time‐dependent net reclassification improvement and integrated discrimination improvement. The median age of patients was 85 years (quartile 82–88), and 29.2% of the study population were men. The median Society of Thoracic Surgeons score was 6.8 (4.7–9.5), and BNP at discharge was 186 (93–378) pg/mL. All‐cause mortality following discharge was 7.9% (95% CI, 5.8–9.9%) at 1 year and 15.4% (95% CI, 11.6–19.0%) at 2 years. The survival classification and regression tree analysis revealed that the discriminating BNP level to discern 2‐year mortality was 202 pg/mL, and that elevated BNP had a statistically significant impact on outcomes, with an adjusted hazard ratio of 2.28 (1.36–3.82, P=0.002). The time‐dependent net reclassification improvement (P=0.047) and integrated discrimination improvement (P=0.029) analysis revealed that the incorporation of BNP stratification with other clinical variables significantly improved predictive accuracy for 2‐year mortality.

Conclusions

Elevation of BNP at discharge is associated with 2‐year mortality after transcatheter aortic valve replacement.

Determining the impact of 24/7 phone support on hospital readmissions after aortic valve replacement surgery (the AVRre study): study protocol for a randomised controlled trial

BACKGROUND

Patients undergoing surgical aortic valve replacement (sAVR) have high rates of 30-day readmissions. They also report a low health-related quality of life (HRQOL) and elevated anxiety and depression. The aim of the AVRre study is to determine the efficacy and cost of a 24/7 phone-support intervention in reducing post-discharge readmissions after sAVR. The nature of the support is to help patients better understand and self-manage non-urgent symptoms at home.

METHODS/DESIGN

AVRre is a prospective, randomised controlled study comprising 30 days of continuous phone-support intervention and then intermittent follow-up for the first 12 months. Phone call data from and to patients are evaluated qualitatively; thus, the study has a mixed-method design. Two hundred and eighty-six patients, aged >18 years, scheduled for a sAVR - singly or in combination with another procedure - are recruited from locations in southeast Norway. Patients are randomly assigned to the intervention group, who are purposively phone-called individually 2 and 9 days after discharge and offered on-demand 24/7 (around-the-clock) telephone support for 30 days post-discharge. The primary outcome variable is the number of 30-day hospital readmissions. Secondary outcomes are anxiety and depression symptoms, as measured by the Hospital Anxiety and Depression Scale, HRQOL and quality-adjusted life years, measured by the EuroQol (EQ-5D). Intervention and hospital readmission (diagnosis-related groups (DRGs)/length of stay) for the first year after initial discharge from hospital are used for a cost-utility analysis. Standard parametric and non-parametric tests are used for evaluations over time. Analysis of covariance is used to control for possible differences at baseline. Narratives from phone calls are transcribed verbatim and analysed using systematic text condensation.

DISCUSSION

A complex 'around-the-clock' intervention within a university hospital-based setting could be an effective strategy to reduce the high readmission rates to hospital after sAVR. Furthermore, the AVRre 24/7 phone-support manual can be adapted to other high-risk surgery populations with high readmission rates.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02522663 . Registered on 11 August 2015.

Readmission rates after transcatheter aortic valve replacement in high- and extreme-risk patients with severe aortic stenosis

OBJECTIVE

In high- or extreme-risk patients undergoing transcatheter aortic valve replacement, readmissions have not been adequately studied and are the subject of increased scrutiny by healthcare systems. The objectives of this study were to determine the incidence of 30-day and 1-year cardiac and noncardiac readmissions, identify predictors of readmission, and assess the association between readmission and 1-year mortality.

METHODS

A retrospective review was performed on 714 patients who underwent transcatheter aortic valve replacement from September 2007 to January 2015 at Emory University.

RESULTS

Patients' median age was 83 years, and 46.6% were female. Early all-cause readmission for the cohort was 10.5%, and late readmission was 18.8%. Anemia was related to both early all-cause (hazard ratio [HR], 0.74) and cardiovascular-related readmission (HR, 0.60). A 23-mm valve implanted was associated with early all-cause readmission (HR, 1.73). Length of hospital stay was related to late all-cause (HR, 1.14) and cardiovascular-related readmission (HR, 1.21). Postoperative permanent stroke had an impact on late cardiovascular-related readmission (HR, 3.60; 95% confidence interval, 1.13-11.49). Multivariable analysis identified anemia as being associated with 30-day all-cause readmission, and anemia and postoperative stroke were associated with 30-day cardiovascular-related readmission. Readmissions seemed to be related to 1-year mortality (HR, 2.04; 95% confidence interval, 1.33-3.12).

CONCLUSIONS

We show some baseline comorbidities and procedural complications that are directly associated with early and late readmissions, and anemia and postoperative stroke were associated with an increase in mortality. Moreover, we found that readmission was associated with double the hazard of death within 1 year. Whether treatment of identified risk factors could decrease readmission rates and mortality warrants further investigation.

Reengineering valve patients' postdischarge management for adapting to bundled payment models

BACKGROUND

Bundled Payments for Care Improvement (BPCI) initiatives were developed by Medicare in an effort to reduce expenditures while preserving quality of care. Payment model 2 reimburses based on a target price for 90-day episode of care postprocedure. The challenge for valve patients is the historically high (>35%) 90-day readmission rate. We analyzed our institutional cardiac surgical service line adaptation to this initiative.

METHODS

On May 1, 2015, we instituted a readmission reduction initiative (RRI) that included presurgical risk stratification, comprehensive predischarge planning, and standardized postdischarge management led by cardiac nurse practitioners (CNPs) who attempt to guide any postdischarge encounters (PDEs). A prospective database also was developed, accruing data on all cardiac surgery patients discharged after RRI initiation. We analyzed detailed PDEs for all valve patients with complete 30-day follow-up through November 2015.

RESULTS

Patients included 219 surgical patients and 126 transcatheter patients. Sixty-four patients had 79 PDEs. Of these 79 PDEs, 46 (58.2%) were guided by CNPs. PDEs were due to fluid overload/effusion (21, 27%), arrhythmia (17, 22%), bleeding/thromboembolic events (13, 16%), and falls/somatic complaints (12, 15%). Thirty-day readmission rate was 10.1% (35/345). Patients with transcatheter aortic valve replacement had a higher rate of readmission than surgical patients (15.0% vs 6.9%), but were older with more comorbidities. The median readmission length of stay was 2.0 days (interquartile range 1.0-5.0 days). Compared with 2014, the 30-day readmission rate for BPCI decreased from 18% (44/248) to 11% (20/175), P = .05.

CONCLUSIONS

Our reengineering of pre/postdischarge management of BPCI valve patients under tight CNP control has significantly reduced costly 30-day readmissions in this high-risk population.

Etiologies and Predictors of 30-Day Readmission and In-Hospital Mortality During Primary and Readmission After Transcatheter Aortic Valve Implantation

There are sparse data on the etiologies and predictors of readmission after transcatheter aortic valve implantation (TAVI). The study cohort was derived from the National Readmission Data 2013, a subset of the Healthcare Cost and Utilization Project sponsored by the Agency for Healthcare Research and Quality. TAVI was identified using appropriate International Classification of Diseases, Ninth Revision, Clinical Modification codes. The coprimary outcomes were 30-day readmissions and in-hospital mortality during primary admission and readmission. Hierarchical 2-level logistic models were used to evaluate study outcomes. Our analysis included 5,702 (weighted n = 12,703) TAVI procedures. About 1,215 patients were readmitted (weighted n = 2,757) within 30 days during the study year. Significant predictors of readmission included transapical access (OR, 95% CI, p value) (1.23, 1.10 to 1.38, <0.01), diabetes (1.18, 1.06 to 1.32, p 0.004), chronic lung disease (1.32, 1.18 to 1.47, <0.01), renal failure (1.43, 1.24 to 1.65, <0.01), patients discharged to facilities (1.28, 1.14 to 1.43, <0.01), and those who had lengthier hospital stays during primary admission (length of stay >10 days: 3.06, 2.22 to 4.22, <0.01). Female gender (1.39, 1.16 to 1.68, <0.01), blood transfusion (1.88, 1.55 to 2.29, <0.01), use of vasopressors (3.63, 2.50 to 5.28, <0.01), hemodynamic support (6.39, 5.20 to 7.85, <0.01) and percutaneous coronary intervention (1.89, 1.30 to 2.74, 0.01) during primary admission were significant predictors of in-hospital mortality. Age and transapical access were significant predictors of in-hospital mortality during readmission. In conclusion, heart failure, pneumonia, and bleeding complications are among important etiologies of readmission in patients after TAVI. Patients who underwent transapical TAVI and those with slower in-hospital recovery and co-morbidities such as chronic lung disease and renal failure are more likely to be readmitted to the hospital.

Readmissions and mortality in delirious versus non-delirious octogenarian patients after aortic valve therapy: a prospective cohort study

OBJECTIVES

To determine whether postoperative delirium predicts first-time readmissions and mortality in octogenarian patients within 180 days after aortic valve therapy with surgical aortic valve replacement (SAVR) or transcatheter aortic valve implantation (TAVI), and to determine the most common diagnoses at readmission.

DESIGN

Prospective cohort study of patients undergoing elective SAVR or TAVI.

SETTING

Tertiary university hospital that performs all SAVRs and TAVIs in Western Norway.

PARTICIPANTS

Patients 80+ years scheduled for SAVR or TAVI and willing to participate in the study were eligible. Those unable to speak Norwegian were excluded. Overall, 143 patients were included, and data from 136 are presented.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was a composite variable of time from discharge to first all-cause readmission or death. Secondary outcomes were all-cause first readmission alone and mortality within 180 days after discharge, and the primary diagnosis at discharge from first-time readmission. Delirium was assessed with the confusion assessment method. First-time readmissions, diagnoses and mortality were identified in hospital information registries.

RESULTS

Delirium was identified in 56% of patients. The effect of delirium on readmissions and mortality was greatest during the first 2 months after discharge (adjusted HR 2.9 (95% CI 1.5 to 5.7)). Of 30 first-time readmissions occurring within 30 days, 24 (80%) were patients who experienced delirium. 1 patient (non-delirium group) died within 30 days after therapy. Delirious patients comprised 35 (64%) of 55 first-time readmissions occurring within 180 days. Circulatory system diseases and injuries were common causes of first-time readmissions within 180 days in delirious patients. 8 patients died 180 days after the procedure; 6 (75%) of them experienced delirium.

CONCLUSIONS

Delirium in octogenarians after aortic valve therapy might be a serious risk factor for postoperative morbidity and mortality. Cardiovascular disorders and injuries were associated with first-time readmissions in these patients.