Outcomes, readmissions, and costs in transfemoral and alterative access transcatheter aortic valve replacement in the US Medicare population

J Thorac Cardiovasc Surg. 2017 Oct;154(4):1224-1232.e1. doi: 10.1016/j.jtcvs.2017.04.090. Epub 2017 Jun 16.

Abstract

Objective: To comprehensively evaluate and compare utilization, outcomes, and especially costs of transfemoral (TF), transapical (TA), and transaortic (TAO) transcatheter aortic valve replacement (TAVR).

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 with 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 < .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 (hazard ratio, 2.13; P < .01) and increased 30-day cost ($62,000 [interquartile range (IQR)], $45,100-$86,400 versus $48,800 [IQR, $38,100-$62,900]; P < .01). Cost at 30 days was lowest for TF ($48,600) compared with TA ($49,800; P < .01) and TAO ($53,200; P = .03).

Conclusions: For patients ineligible to receive TF TAVR, TAO and TA approaches offer similar clinical outcomes at similar cost with acceptable operative and 1-year survival, except for higher rates of CPB use in TA patients. CPB was associated with worse survival and increased costs.

Keywords: TAVR; alternative access; cost; transapical; transfemoral.

MeSH terms

  • Aged
  • Aged, 80 and over
  • Aorta / surgery
  • Aortic Valve Stenosis* / economics
  • Aortic Valve Stenosis* / mortality
  • Aortic Valve Stenosis* / surgery
  • Catheterization, Peripheral* / methods
  • Catheterization, Peripheral* / statistics & numerical data
  • 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
  • Transcatheter Aortic Valve Replacement* / adverse effects
  • Transcatheter Aortic Valve Replacement* / economics
  • Transcatheter Aortic Valve Replacement* / methods
  • Transcatheter Aortic Valve Replacement* / statistics & numerical data
  • Treatment Outcome
  • United States / epidemiology