Decision-making in transcatheter aortic valve replacement: the impact of frailty in older adults with aortic stenosis

Two-year post-discharge costs of care among patients treated with transcatheter or surgical aortic valve replacement in Germany

Background

This study presents data on post-discharge costs of care among patients treated with transcatheter or surgical aortic valve replacement over a two year period.

Methods

Based on a prospective clinical trial, post-discharge utilization of health services and status of assistance were collected for 151 elderly patients via 2250 monthly telephone interviews, valued using standardized unit costs and analysed using two-part regression models.

Results

At month 1 post-discharge, total costs of care are substantially elevated (monthly mean: €3506.7) and then remain relatively stable over the following 23 months (monthly mean: €622.3). As expected, the majority of these costs are related to in-hospital care (~98% in month 1 post-discharge and ~72% in months 2–24). Patients that died during follow-up were associated with substantially higher cost estimates of in-hospital care than those surviving the two-year study period, while patients’ age and other patient characteristics were of minor relevance. Estimated costs of outpatient care are lower at month 1 than during the rest of the study period, and not affected by the event of death during follow-up. The estimated costs of nursing care are, in contrast, much higher in year 2 than in year 1 and differ substantially by gender and type of procedure as well as by patients’ age. Overall, these monthly cost estimates add up to €10,352 for the first and €7467.6 for the second year post-discharge.

Conclusions

Substantial cost increases at month 1 post-discharge and in case of death during follow-up are the main findings of the study, which should be taken into account in future economic evaluations on the topic. Application of standardized unit costs in combination with monthly patient interviews allows for a far more precise estimate of the variability in post-discharge health service utilization in this group of patients than the ones given in previous studies.

Trial registration

German Clinical Trial Register Nr. DRKS00000797.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2432-8) contains supplementary material, which is available to authorized users.

The impact of frailty on mortality after transcatheter aortic valve replacement

Frailty is a notably common problem in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR) evaluation. Studies have demonstrated significant associations between frailty and worse outcomes in patients undergoing TAVR including higher risks of disability and mortality and admissions to long-term care facility. While there are multiple methods to identify and measure frailty, there is a critical need for a precise definition of frailty and its standardized assessment protocol based on well-established tests covering all aspects of the frailty, as a syndrome. Incorporation of the available frailty evaluation into pre-operative risk assessments chances of morbidity or mortality following surgery can help enhancing performance and improve shared decision-making between physicians and their patients. In this review, we present the perspectives of the impact of frailty on mortality in patients undergoing TAVR.

"Heart Team" decision making in elderly patients with symptomatic aortic valve stenosis who underwent AVR or TAVI - a look behind the curtain. Results of the prospective TAVI Calculation of Costs Trial (TCCT)

AIMS

Little is known about how "Heart Team" treatment decisions among patients suitable for either surgical aortic valve replacement (AVR) or transcatheter aortic valve implantation (TAVI) are made under routine conditions.

METHODS AND RESULTS

The "Heart Team" decision-making process was analysed with respect to124 patients of a non-randomised prospective clinical trial that included patients aged ≥75 years: 41 patients underwent AVR and 83 underwent TAVI. By use of the non-parametric classification and regression tree (CART) methodology, 21 baseline parameters were tested to reconstruct the decision process retrospectively. Next, multivariate logistic and Cox regression models were fitted to evaluate the decision and outcome relevance (two-year survival) of the parameters as identified in the CART procedure. For patients with a baseline EuroSCORE I ≥13.48%, no further cut-off points were identified and the majority of these patients underwent TAVI. Among patients with a baseline EuroSCORE I <13.48%, age and left ventricular ejection fraction (LVEF) were identified as further relevant decision parameters. The decision relevance of EuroSCORE I (p=0.003), age (p=0.024) and LVEF (p=0.047) were confirmed by multivariate analysis; however, outcome relevance can be confirmed for EuroSCORE I (p=0.015) only, while treatment decision (TAVI or AVR) was not a significant predictor of mortality (p=0.655).

CONCLUSIONS

Despite or even because of the systematic risk selection according to EuroSCORE I values, we observed two-year survival rates of about 75% regardless of whether the patient received TAVI or AVR, suggesting that the decisions made by the "Heart Team" were appropriate.

Geriatric Cardiology: An Emerging Discipline

Given changing demographics, patients with cardiovascular (CV) disease in developed countries are now older and more complex than even a decade ago. This trend is expected to continue into the foreseeable future; accordingly, cardiologists are encountering patients with a greater number of comorbid illnesses as well as "geriatric conditions," such as cognitive impairment and frailty, which complicate management and influence outcomes. Simultaneously, technological advances have widened the therapeutic options available for patients, including those with the most advanced CV disease. In the setting of these changes, geriatric cardiology has recently emerged as a discipline that aims to adapt principles from geriatric medicine to everyday cardiology practice. Accordingly, the tasks of a "geriatric cardiologist" may include both traditional evidence-based CV management plus comprehensive geriatric assessment, medication reduction, team-based coordination of care, and explicit incorporation of patient goals into management. Given that the field is still in its relative infancy, the training pathways and structure of clinical programs in geriatric cardiology are still being delineated. In this review, we highlight the rationale behind geriatric cardiology as a discipline, several current approaches by geriatric cardiology programs, and future directions for the field.

Frailty and post-operative outcomes in older surgical patients: a systematic review

Background

As the population ages, increasing numbers of older adults are undergoing surgery. Frailty is prevalent in older adults and may be a better predictor of post-operative morbidity and mortality than chronological age. The aim of this review was to examine the impact of frailty on adverse outcomes in the ‘older old’ and ‘oldest old’ surgical patients.

Methods

A systematic review was undertaken. Electronic databases from 2010 to 2015 were searched to identify articles which evaluated the relationship between frailty and post-operative outcomes in surgical populations with a mean age of 75 and older. Articles were excluded if they were in non-English languages or if frailty was measured using a single marker only. Demographic data, type of surgery performed, frailty measure and impact of frailty on adverse outcomes were extracted from the selected studies. Quality of the studies and risk of bias was assessed by the Epidemiological Appraisal Instrument.

Results

Twenty-three studies were selected for the review and they were assessed as medium to high quality. The mean age ranged from 75 to 87 years, and included patients undergoing cardiac, oncological, general, vascular and hip fracture surgeries. There were 21 different instruments used to measure frailty. Regardless of how frailty was measured, the strongest evidence in terms of numbers of studies, consistency of results and study quality was for associations between frailty and increased mortality at 30 days, 90 days and one year follow-up, post-operative complications and length of stay. A small number of studies reported on discharge to institutional care, functional decline and lower quality of life after surgery, and also found a significant association with frailty.

Conclusion

There was strong evidence that frailty in older-old and oldest-old surgical patients predicts post-operative mortality, complications, and prolonged length of stay. Frailty assessment may be a valuable tool in peri-operative assessment. It is possible that different frailty tools are best suited for different acuity and type of surgical patients. The association between frailty and return to pre-morbid function, discharge destination, and quality of life after surgery warrants further research.

The Application of Frailty to the Modern Cardiac Risk Assessment: a Case-Based Review

Cardiac risk assessment in aging patients poses a significant challenge to the practicing clinician, particularly when evaluating the use of invasive procedures. Frailty is a valuable risk marker that has been associated with worse outcomes in patients with coronary artery disease, heart failure, and aortic stenosis. Integrating the available frailty studies into cardiac risk assessments can help improve shared decision-making between physicians and their patients. In this review, we provide an up-to-date, case-based appraisal of the available clinical trial data focusing on the impact of frailty in patients with cardiovascular disease.

Transcatheter aortic valve implantation in the elderly: who to refer?

In recent years, experience with transcatheter aortic valve implantation has led to improved outcomes in elderly patients with severe aortic stenosis (AS) who may not have previously been considered for intervention. These patients are often frail with significant comorbid conditions. As the prevalence of AS increases, there is a need for improved assessment parameters to determine the patients most likely to benefit from this novel procedure. This review discusses the diagnostic criteria for severe AS and the trials available to aid in the decision to refer for aortic valve procedures in the elderly.

Cardiac imaging in the geriatric population: what do we think we know, and what do we need to learn?

Cardiac imaging plays an important role in coronary artery disease (CAD), congestive heart failure (HF) and valvular heart disease (VHD) in the elderly. Imaging defines the structure and function of the cardiac system, refining the understanding of patients' anatomy and physiology and informing a host of clinical care decisions, including prognosis. Yet there is a paucity of evidence to guide the rational use of many imaging modalities in patients of advanced age, a population with considerable clinical heterogeneity, high prevalence and burden of cardiovascular disease (CVD) and atypical presentations of CVD. This paper discusses important considerations for cardiac imaging for older adults, particularly in regard to CAD, VHD and HF, and then presents domains for future research to produce data that would inform clinical care guidelines, appropriate use criteria and imaging lab protocols to address the unique needs of the fast-growing elderly population.