• A Novel Patient-Centered Metric May Improve Risk Stratification in TAVR, Study Suggests

    Home time is associated with risk-adjusted readmission and mortality rate, representing a novel patient-centered metric that might complement currently used metrics in transcatheter aortic valve replacement (TAVR).

    Currently utilized metrics in TAVR capture patient-level risk, case mix, and postprocedural care quality. However, the post-discharge period remains unaccounted for in many of the currently used metrics in TAVR. This is of particular concern in older patients who undergo TAVR, as they demonstrate a higher burden of functional impairment, frailty, and difficulty in self-care.

    Amgad Mentias, MD, MS, of the Cleveland Clinic Foundation, and co-investigators examined 160,792 Medicare beneficiaries who underwent TAVR between 2015 and 2019. The authors sought to evaluate a novel patient-centered metric called home time, which was defined as the number of days, within the first 30 days after TAVR, spent alive at home outside of a hospital or a skilled nursing facility (acute or subacute). They then examined the correlation between 30-day home time and 30-day risk-adjusted readmission rate (RSRR), risk-adjusted mortality rate (RSMR) and annual TAVR volume.

    The median risk-adjusted, 30-day home time was 27.4 days (interquartile range [IQR], 26.3-28.5 days). The largest proportion of non-home time days following TAVR were spent in a skilled nursing facility. Home time was inversely related to hospital-level, risk-adjusted, 30-day RSRR (r=0.4650, p<0.001) and 30-day RSMR (r=0.3996, p<0.001). Reclassification of in-hospital performance occurred with the use of home time (9.1% up-classified, 11.2% down-classified vs RSRR; 9.1% up-classified, 10.3% down-classified vs RSMR; and 20.1% up-classified, 19.3% down-classified vs annual TAVR volume).

    The authors conclude that risk-adjusted 30-day home time can be estimated using administrative claims data and that it is a meaningful, patient-centered measure.

     

    Matthew W. Sherwood, MD, of Inova Heart and Vascular Institute, Falls Church, Virginia, and Duke Clinical Research Institute, Durham, North Carolina, and Amit N. Vora, MD, of the University of Pennsylvania Medical Center Heart and Vascular Institute, Harrisburg, and Duke University Medical Center, wrote an accompanying editorial to the study. In it, they congratulates the investigators for bringing the valuable concept of home time, which had previously been studied in other aspects of cardiovascular medicine, to TAVR. They point out that there is a strong incentive to minimize the length of stay in TAVR, as it does not currently fall within a bundled payment schema with penalties for rehospitalization. Home time can be a useful metric to identify certain patients in whom early discharge may not be as heavily incentivized. They conclude that the development of metrics such as home time will improve TAVR outcomes, helping physicians better understand patients and their risk following TAVR in order to discourage risk-averse behaviors.

     

    Sources:

    Mentias A, Keshvani N, Desai MY, et al. Risk-Adjusted, 30-Day Home Time After Transcatheter Aortic Valve Replacement as a Hospital-Level Performance Metric. J Am Coll Cardiol 2022;79:132–144.

    Sherwood MW, Vora AN. For TAVR, Home Is Where the Heart Is. J Am Coll Cardiol 2022;79:145–147.

    Image Credit: Seventyfour stock.adobe.com

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