In an analysis of the Transcatheter Valve Therapy (TVT) Registry of reported stroke in Michigan, hospitals with a designation of Comprehensive Stroke Center (CSC) were found to be associated with a higher 30-day stroke rate after transcatheter aortic valve replacement (TAVR), in comparison with non-CSC institutions.
P. Michael Grossman, MD of the University of Michigan, and colleagues reported these findings in a manuscript published Monday online and in the Jan. 23 issue of JACC: Cardiovascular Interventions.
Stroke after TAVR is an important metric that indicates of quality and safety of TAVR performed at a given institution. However, differences in the dedication to ascertaining stroke events bias stroke rates among institutions. Grossman and colleagues aimed to investigate the effect of CSC designation on stroke rate while adjusting for differences in baseline risk factors for stroke.
The authors queried the TVT Registry data submitted by 22 Michigan institutions. There were 3,882 (62.3%) patients at nine CSC sites and 2,349 (37.7%) patients at 13 non-CSC sites. Mean age across all patients was 79 years old, and 46% were female.
CSC sites had significantly higher rates of in-hospital post-TAVR stroke (CSC: 2.65% vs non-CSC: 1.15%; P < 0.001). This association was maintained after adjustment (odds ratio: 2.21; 95% CI: 1.03-4.62). Importantly, CSC designation was not associated with other clinical outcomes such as 30 day mortality, acute kidney injury or transfusion.
Alexandra Lansky, MD, and Yousif Ahmed, PhD, of the Yale School of Medicine wrote the editorial comment. The editorialists contextualized the study, explaining that the differences in CSC vs. non CSC stroke rate can be likened to the differences in outcomes between trial data and registry data; when ascertainment of events is more stringent, as in clinical trials, event rates tend to be higher.
They emphasized the cautionary argument presented in the manuscript: public reporting, while intended to improve quality, may inadvertently incentivize institutions toward under-reporting or otherwise avoiding high risk patients who may benefit from intervention.
The editorialists wrote: “… it is necessary to thoughtfully select metrics that will lead to the intended improvements in quality and patient outcomes rather than metrics that may affect physician or institutional behavior to the detriment of best practices and patient care.”
Grossman PM, Sukul D, Lall SC, et al. The Relationship Between Hospital Stroke Center Designation and TVT Reported Stroke: The Michigan TAVR Experience. JACC Cardiovasc Interv 2023;16:168–176.
Lansky AJ, Ahmad Y. Public Reporting of Stroke After Transcatheter Aortic Valve Replacement: A Cautionary Tale. JACC Cardiovasc Interv 2023;16:168–176.
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