Association Between Patient Survival and Clinician Variability in Treatment Rates for Aortic Valve Stenosis

Author:

Brennan J. Matthew1ORCID,Lowenstern Angela1ORCID,Sheridan Paige23ORCID,Boero Isabel J.3,Thourani Vinod H.4,Vemulapalli Sreekanth1ORCID,Wang Tracy Y.1,Liska Otto3,Gander Stuart3,Jager Jason3,Leon Martin B.5,Peterson Eric D.1ORCID

Affiliation:

1. Duke Clinical Research Institute Duke University School of Medicine Durham NC

2. Department of Family Medicine and Public Health University of California, San Diego School of Medicine San Diego CA

3. Boston Consulting Group Boston MA

4. Department of Cardiovascular Surgery Piedmont Heart Institute Atlanta GA

5. Columbia University Irving Medical Center and New York Presbyterian Hospital New York NY

Abstract

Background Patients with symptomatic severe aortic stenosis (ssAS) have a high mortality risk and compromised quality of life. Surgical/transcatheter aortic valve replacement (AVR) is a Class I recommendation, but it is unclear if this recommendation is uniformly applied. We determined the impact of managing cardiologists on the likelihood of ssAS treatment. Methods and Results Using natural language processing of Optum electronic health records, we identified 26 438 patients with newly diagnosed ssAS (2011–2016). Multilevel, multivariable Fine‐Gray competing risk models clustered by cardiologists were used to determine the impact of cardiologists on the likelihood of 1‐year AVR treatment. Within 1 year of diagnosis, 35.6% of patients with ssAS received an AVR; however, rates varied widely among managing cardiologists (0%, lowest quartile; 100%, highest quartile [median, 29.6%; 25th–75th percentiles, 13.3%–47.0%]). The odds of receiving AVR varied >2‐fold depending on the cardiologist (median odds ratio for AVR, 2.25; 95% CI, 2.14–2.36). Compared with patients with ssAS of cardiologists with the highest treatment rates, those treated by cardiologists with the lowest AVR rates experienced significantly higher 1‐year mortality (lowest quartile, adjusted hazard ratio, 1.22, 95% CI, 1.13–1.33). Conclusions Overall AVR rates for ssAS were low, highlighting a potential challenge for ssAS management in the United States. Cardiologist AVR use varied substantially; patients treated by cardiologists with lower AVR rates had higher mortality rates than those treated by cardiologists with higher AVR rates.

Publisher

Ovid Technologies (Wolters Kluwer Health)

Subject

Cardiology and Cardiovascular Medicine

Reference43 articles.

1. 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

2. 5-year outcomes of transcatheter aortic valve replacement or surgical aortic valve replacement for high surgical risk patients with aortic stenosis (PARTNER 1): a randomised controlled trial

3. Health Status Benefits of Transcatheter vs Surgical Aortic Valve Replacement in Patients With Severe Aortic Stenosis at Intermediate Surgical Risk

4. ClinicalTrials.gov . PARTNER 3 trial: the safety and effectiveness of the SAPIEN 3 transcatheter heart valve in low risk patients with aortic stenosis (P3). ClinicalTrials.gov web site. Updated April 8 2021. Available at: https://clinicaltrials.gov/ct2/show/NCT02675114. Accessed November 1 2019.

5. ClinicalTrials.gov Medtronic evolut transcatheter aortic valve replacement in low risk patients. ClinicalTrials.gov web site. Available at: https://clinicaltrials.gov/ct2/show/NCT02701283. Updated October 30 2019. Accessed November 1 2019.

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