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Qeska D, Qiu F, Manoragavan R, Wijeysundera HC, Cheung CC. RELATIONSHIP BETWEEN WAIT-TIMES AND POST-ATRIAL FIBRILLATION ABLATION OUTCOMES: A POPULATION BASED STUDY. Heart Rhythm 2024:S1547-5271(24)02370-1. [PMID: 38608920 DOI: 10.1016/j.hrthm.2024.04.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 04/03/2024] [Accepted: 04/07/2024] [Indexed: 04/14/2024]
Abstract
BACKGROUND Rhythm control is a cornerstone of atrial fibrillation (AF) management. Shorter time between diagnosis of AF and receipt of catheter ablation is associated with greater rates of therapy success. Prior work considered diagnosis-to-ablation time as a binary or categorical variable and did not consider the unique risk profile of patients once a referral for ablation is made. OBJECTIVES Comprehensively assess the impact of diagnosis-to-ablation and referral-to-ablation time on post-procedural outcomes at a population level. METHODS This observational cohort study included patients who received catheter ablation to treat AF in Ontario, Canada. Patient demographics, medical comorbidities, AF diagnosis date, ablation referral date, and ablation date were collected. The primary outcomes of interest included a composite of death and hospitalization/emergency department visit for AF, heart failure, or ischemic stroke. Multivariable Cox models assessed the impact of diagnosis-to-ablation and referral-to-ablation times on the primary outcome. RESULTS Our cohort included 7,472 patients who received ablation for de novo AF between April 1, 2016 and March 31, 2022. The median diagnosis-to-ablation time was 718 (IQR:399-1274) days and the median referral-to-ablation time was 221 (IQR:117-363) days. Overall, 911 (12.2%) patients had the composite endpoint within one year of ablation. Increasing diagnosis-to-ablation time was associated with a greater incidence for the primary outcome (HR:1.02 [95%CI: 1.01-1.02] per month). Increasing referral-to-ablation time did not impact the primary outcome (HR:1.00 [95%CI: 0.98-1.01] per month). CONCLUSION Delays between AF diagnosis and ablation referral may contribute to adverse post-procedural outcomes, and provide an opportunity for health system quality improvements.
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Affiliation(s)
- Denis Qeska
- Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada; Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | | | - Ragavie Manoragavan
- Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Harindra C Wijeysundera
- Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada; Temerty Faculty of Medicine, University of Toronto, Toronto, Canada; ICES, Toronto, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.
| | - Christopher C Cheung
- Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada; Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
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Miranda RN, Qiu F, Manoragavan R, Austin PC, Naimark DMJ, Fremes SE, Ko DT, Madan M, Mamas MA, Sud MK, Tam D, Wijeysundera HC. Transcatheter Aortic Valve Implantation Wait-Time Management: Derivation and Validation of the Canadian TAVI Triage Tool (CAN3T). J Am Heart Assoc 2024; 13:e033768. [PMID: 38390797 PMCID: PMC10944064 DOI: 10.1161/jaha.123.033768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 01/26/2024] [Indexed: 02/24/2024]
Abstract
BACKGROUND Transcatheter aortic valve implantation (TAVI) has seen indication expansion and thus exponential growth in demand over the past decade. In many jurisdictions, the growing demand has outpaced capacity, increasing wait times and preprocedural adverse events. In this study, we derived prediction models that estimate the risk of adverse events on the waitlist and developed a triage tool to identify patients who should be prioritized for TAVI. METHODS AND RESULTS We included adult patients in Ontario, Canada referred for TAVI and followed up until one of the following events first occurred: death, TAVI procedure, removal from waitlist, or end of the observation period. We used subdistribution hazards models to find significant predictors for each of the following outcomes: (1) all-cause death while on the waitlist; (2) all-cause hospitalization while on the waitlist; (3) receipt of urgent TAVI; and (4) a composite outcome. The median predicted risk at 12 weeks was chosen as a threshold for a maximum acceptable risk while on the waitlist and incorporated in the triage tool to recommend individualized wait times. Of 13 128 patients, 586 died while on the waitlist, and 4343 had at least 1 hospitalization. A total of 6854 TAVIs were completed, of which 1135 were urgent procedures. We were able to create parsimonious models for each outcome that included clinically relevant predictors. CONCLUSIONS The Canadian TAVI Triage Tool (CAN3T) is a triage tool to assist clinicians in the prioritization of patients who should have timely access to TAVI. We anticipate that the CAN3T will be a valuable tool as it may improve equity in access to care, reduce preventable adverse events, and improve system efficiency.
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Affiliation(s)
- Rafael N. Miranda
- Institute of Health Policy, Management and EvaluationUniversity of TorontoCanada
| | | | - Ragavie Manoragavan
- Schulich Heart Program, Sunnybrook Health Sciences CentreUniversity of TorontoCanada
| | - Peter C. Austin
- Institute of Health Policy, Management and EvaluationUniversity of TorontoCanada
- ICESTorontoCanada
| | - David M. J. Naimark
- Institute of Health Policy, Management and EvaluationUniversity of TorontoCanada
- Temerty Faculty of MedicineUniversity of TorontoCanada
| | - Stephen E. Fremes
- Institute of Health Policy, Management and EvaluationUniversity of TorontoCanada
- ICESTorontoCanada
- Schulich Heart Program, Sunnybrook Health Sciences CentreUniversity of TorontoCanada
- Temerty Faculty of MedicineUniversity of TorontoCanada
| | - Dennis T. Ko
- ICESTorontoCanada
- Schulich Heart Program, Sunnybrook Health Sciences CentreUniversity of TorontoCanada
- Temerty Faculty of MedicineUniversity of TorontoCanada
| | - Mina Madan
- Schulich Heart Program, Sunnybrook Health Sciences CentreUniversity of TorontoCanada
| | - Mamas A. Mamas
- Keele Cardiovascular Research Group, School of MedicineKeele UniversityStoke‐on‐TrentUnited Kingdom
| | - Maneesh K. Sud
- ICESTorontoCanada
- Schulich Heart Program, Sunnybrook Health Sciences CentreUniversity of TorontoCanada
- Temerty Faculty of MedicineUniversity of TorontoCanada
| | - Derrick Tam
- Schulich Heart Program, Sunnybrook Health Sciences CentreUniversity of TorontoCanada
| | - Harindra C. Wijeysundera
- Institute of Health Policy, Management and EvaluationUniversity of TorontoCanada
- ICESTorontoCanada
- Schulich Heart Program, Sunnybrook Health Sciences CentreUniversity of TorontoCanada
- Temerty Faculty of MedicineUniversity of TorontoCanada
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Sidhu H, Qiu F, Manoragavan R, Ko DT, Mamas MA, Sud M, Tam DY, Wijeysundera HC. Impact of Neighborhood Social Deprivation on Health Care Costs Associated With TAVR. Circ Cardiovasc Qual Outcomes 2023:e009761. [PMID: 37381925 DOI: 10.1161/circoutcomes.122.009761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
BACKGROUND Cumulative costs of transcatheter aortic valve replacement (TAVR) differ in the referral, procedural and postprocedural phases depending on patient comorbidities, type of procedure, and procedural complications. Our goal was to determine the association between neighborhood measures of social deprivation and TAVR costs in each of the 3 phases. METHODS Demographics, patient comorbidities, procedural details, in-hospital complications, and costs for adults undergoing TAVR between 2017 and 2020 in Ontario, Canada were obtained from administrative databases and linked to social deprivation data using the Ontario Marginalization Index. The 3 dimensions of social deprivation assessed were (1) material deprivation, (2) residential instability, and (3) ethnic concentration. Hierarchical generalized linear models were used to determine the association between neighborhood social deprivation and cumulative TAVR costs, reported in 2018 Canadian dollars. RESULTS We identified a total of 7617 TAVR referrals with 3784 patients undergoing TAVR within our study period. Cumulative mean costs in the referral, procedural and postprocedural phases were $8116±$11 374, $32 790±$17 766, and $18 901±$32 490, respectively. After adjustment for clinical and demographic variables, higher factor scores in residential instability were associated with greater cumulative costs in the postprocedural phase, whereas higher factor scores in the other 2 dimensions of marginalization were not significantly associated with higher costs in any of the 3 phases. CONCLUSIONS This analysis shows that residential instability is associated with higher cumulative costs in the postprocedural phase of TAVR. This lays the foundation for future studies to understand the mechanism of this finding and identify potential mitigation policies.
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Affiliation(s)
- Hasrit Sidhu
- Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, Canada. (H.S., R.M., D.K., M.S., H.C.W.)
- Temerty Faculty of Medicine, University of Toronto, Canada. (H.S., D.K., M.S., H.C.W.)
| | - Feng Qiu
- ICES, Toronto, Canada (F.Q., D.K., H.C.W.)
| | - Ragavie Manoragavan
- Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, Canada. (H.S., R.M., D.K., M.S., H.C.W.)
| | - Dennis T Ko
- Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, Canada. (H.S., R.M., D.K., M.S., H.C.W.)
- Temerty Faculty of Medicine, University of Toronto, Canada. (H.S., D.K., M.S., H.C.W.)
- ICES, Toronto, Canada (F.Q., D.K., H.C.W.)
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Institute for Prognosis Research, University of Keele, United Kingdon (M.A.M.)
| | - Maneesh Sud
- Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, Canada. (H.S., R.M., D.K., M.S., H.C.W.)
- Temerty Faculty of Medicine, University of Toronto, Canada. (H.S., D.K., M.S., H.C.W.)
- Institute of Health Policy, Management and Evaluation, University of Toronto, Canada. (M.S., D.T., H.C.W.)
| | - Derrick Y Tam
- Institute of Health Policy, Management and Evaluation, University of Toronto, Canada. (M.S., D.T., H.C.W.)
- Division of Cardiac Surgery, Schulich Heart Centre, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Canada. (D.T.)
| | - Harindra C Wijeysundera
- Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, Canada. (H.S., R.M., D.K., M.S., H.C.W.)
- Temerty Faculty of Medicine, University of Toronto, Canada. (H.S., D.K., M.S., H.C.W.)
- Institute of Health Policy, Management and Evaluation, University of Toronto, Canada. (M.S., D.T., H.C.W.)
- ICES, Toronto, Canada (F.Q., D.K., H.C.W.)
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Qeska D, Singh SM, Qiu F, Manoragavan R, Cheung CC, Ko DT, Sud M, Terricabras M, Wijeysundera HC. Variation and clinical consequences of wait-times for atrial fibrillation ablation: population level study in Ontario, Canada. Europace 2023; 25:euad074. [PMID: 36942997 PMCID: PMC10227764 DOI: 10.1093/europace/euad074] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 02/16/2023] [Indexed: 03/23/2023] Open
Abstract
AIMS Atrial fibrillation (AF) is the most common cardiac rhythm disorder. Emerging evidence supporting the efficacy of catheter ablation in managing AF has led to increased demand for this therapy, potentially outpacing the capacity to perform this procedure. Mismatch between demand and capacity for AF ablation results in wait-times which have not been comprehensively evaluated at a population level. Additionally, the consequences of such delays in AF ablation, namely the risk of hospitalization or adverse events, have not been studied. METHODS AND RESULTS This observational cohort study included adults referred for catheter ablation to treat AF in Ontario, Canada, between 1 April 2016 and 31 March 2020. Wait-time was defined from referral to the earliest of ablation, death, off-list, or the study endpoint of 31 March 2022. The outcomes of interest included a composite of death, hospitalization for AF/heart failure, and emergency department visit for AF/heart failure. Our study cohort included 6253 patients referred for de novo AF ablation. The median wait-time for patients who received and who did not receive ablation was 218 days (IQR: 112-363) and 520 days (IQR: 270-763), respectively. Wait-time increased consistently for patients referred between October 2017 and March 2020. Mortality was rare, but significant morbidity was observed, affecting 19.2% of patients on the waitlist for AF ablation. Paroxysmal AF was associated with a statistically significant greater risk for adverse outcomes on the waitlist (HR 1.51, 95% CI 1.18-1.93). CONCLUSION Wait-times for AF ablation are increasing and are associated with significant morbidity.
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Affiliation(s)
- Denis Qeska
- Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave., Room A202, Toronto, ON M4N 3M5, Canada
- Temerty Faculty of Medicine, University of Toronto, 1 King’s College Circle, Toronto, ON M5S 1A8, Canada
| | - Sheldon M Singh
- Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave., Room A202, Toronto, ON M4N 3M5, Canada
- Temerty Faculty of Medicine, University of Toronto, 1 King’s College Circle, Toronto, ON M5S 1A8, Canada
| | - Feng Qiu
- ICES, 2075 Bayview Ave., Room G1 06, Toronto, ON M4N 3M5, Canada
| | - Ragavie Manoragavan
- Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave., Room A202, Toronto, ON M4N 3M5, Canada
| | - Christopher C Cheung
- Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave., Room A202, Toronto, ON M4N 3M5, Canada
- Temerty Faculty of Medicine, University of Toronto, 1 King’s College Circle, Toronto, ON M5S 1A8, Canada
| | - Dennis T Ko
- Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave., Room A202, Toronto, ON M4N 3M5, Canada
- Temerty Faculty of Medicine, University of Toronto, 1 King’s College Circle, Toronto, ON M5S 1A8, Canada
- ICES, 2075 Bayview Ave., Room G1 06, Toronto, ON M4N 3M5, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College St., Toronto, ON M5T 3M6, Canada
| | - Maneesh Sud
- Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave., Room A202, Toronto, ON M4N 3M5, Canada
- Temerty Faculty of Medicine, University of Toronto, 1 King’s College Circle, Toronto, ON M5S 1A8, Canada
- ICES, 2075 Bayview Ave., Room G1 06, Toronto, ON M4N 3M5, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College St., Toronto, ON M5T 3M6, Canada
| | - Maria Terricabras
- Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave., Room A202, Toronto, ON M4N 3M5, Canada
- Temerty Faculty of Medicine, University of Toronto, 1 King’s College Circle, Toronto, ON M5S 1A8, Canada
| | - Harindra C Wijeysundera
- Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave., Room A202, Toronto, ON M4N 3M5, Canada
- Temerty Faculty of Medicine, University of Toronto, 1 King’s College Circle, Toronto, ON M5S 1A8, Canada
- ICES, 2075 Bayview Ave., Room G1 06, Toronto, ON M4N 3M5, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College St., Toronto, ON M5T 3M6, Canada
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Wijeysundera HC, Gaudino M, Qiu F, Olson MA, Mao J, Manoragavan R, Rong L, Tam DY, Austin PC, Fremes SE, Sedrakyan A. Regional Differences in Outcomes for patients undergoing Transcatheter Aortic Valve Replacement in New York State and Ontario. Can J Cardiol 2023; 39:570-577. [PMID: 36737001 DOI: 10.1016/j.cjca.2023.01.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 12/27/2022] [Accepted: 01/19/2023] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND TAVR has become the standard of care for a wide spectrum of patients with severe aortic stenosis. However, there are wide variations in access to TAVR between jurisdictions. It is unknown if such variation is associated with differences in post-procedural outcomes. Our objective was to determine whether differences in health care delivery in jurisdictions with high versus low access of care to TAVR translate to differences in post-procedural outcomes. METHODS In this observational, retrospective cohort study, we identified all Ontario and New York State residents greater than 18 years of age who received TAVR from January 1st, 2012, to December 31st, 2018. Our primary outcomes were post-TAVR 30 day in-hospital mortality and all cause readmissions. Using indirect standardization, we calculated the observed versus expected outcomes for New York patients, had they been treated in Ontario. RESULTS Our cohort consisted of 16,814 TAVR patients at 36 hospitals in New York State and 5,007 TAVR patients at 11 hospitals in Ontario. In Ontario, TAVR access rates increased from ∼18.2 TAVR/million in 2012 to 87.4 TAVR/million in 2018, while for New York State, the rates increased from 31.9 to 220.4 TAVR/million. For 30-day mortality, 3.1% of Ontario TAVR patients had an in-hospital death, compared to 2.5% of New York patients. With adjustment, this translated to an observed/expected ratio of 0.70 (95% CI 0.54-0.92) for New York patients. CONCLUSIONS Having greater access to TAVR maybe associated with improved outcomes, potentially due to an intervention earlier in the disease trajectory.
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Affiliation(s)
- Harindra C Wijeysundera
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada; Institute for Clinical Evaluative Sciences, Toronto, Canada; Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada; Temerty Faculty of Medicine, University of Toronto, Toronto, Canada.
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Feng Qiu
- Institute for Clinical Evaluative Sciences, Toronto, Canada
| | - Molly A Olson
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, NY, USA
| | - Jialin Mao
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, NY, USA
| | - Ragavie Manoragavan
- Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Lisa Rong
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
| | - Derrick Y Tam
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada; Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada; Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Peter C Austin
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada; Institute for Clinical Evaluative Sciences, Toronto, Canada; Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Stephen E Fremes
- Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada; Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Art Sedrakyan
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, NY, USA
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Patel RV, Ravindran M, Qiu F, Manoragavan R, Sud M, Tam DY, Madan M, Marcus G, Elbaz‐Greener G, Mamas MA, Wijeysundera HC. Social Deprivation and Post-TAVR Outcomes in Ontario, Canada: A Population-Based Study. J Am Heart Assoc 2022; 12:e028144. [PMID: 36565194 PMCID: PMC9973610 DOI: 10.1161/jaha.122.028144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background Transcatheter aortic valve replacement (TAVR)/intervention has become the standard of care for treatment of severe aortic stenosis across the spectrum of risk. There are socioeconomic disparities in access to TAVR. The impact of these disparities on postprocedural outcomes remains unknown. Our objective was to examine the association between neighborhood-level social deprivation and post-TAVR mortality and hospital readmission. Methods and Results We conducted a population-based retrospective cohort study of all 4145 patients in Ontario, Canada, who received TAVR from April 1, 2017, to March 31, 2020. Our co-primary outcomes were 1-year postprocedure mortality and 1-year postprocedure readmission. Using Cox proportional hazards models for mortality and cause-specific competing risk hazard models for readmission, we evaluated the relationship between neighborhood-level measures of residential instability, material deprivation, and concentration of racial and ethnic groups with post-TAVR outcomes. After multivariable adjustment, we found a statistically significant relationship between residential instability and postprocedural 1-year mortality, ranging from a hazard ratio of 1.64 to a hazard ratio of 2.05. There was a significant association between the highest degree of residential instability and 1-year readmission (hazard ratio, 1.23 [95% CI, 1.01-1.49]). There was no association between material deprivation and concentration of racial and ethnic groups with post-TAVR outcomes. Conclusions Residential instability was associated with increased risk for post-TAVR mortality, and the highest quintile of residential instability was associated with increased post-TAVR readmission. To reduce health disparities and promote an equitable health care system, further research and policy interventions will be required to identify and support economically and socially minoritized patients undergoing TAVR.
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Affiliation(s)
- Raumil V. Patel
- Temerty Faculty of MedicineUniversity of TorontoOntarioTorontoCanada,Institute for Health Policy, Management, and EvaluationOntarioTorontoCanada
| | | | - Feng Qiu
- Institute for Clinical Evaluative SciencesOntarioTorontoCanada
| | - Ragavie Manoragavan
- Division of Cardiology, Department of MedicineSchulich Heart Program, Sunnybrook Health Sciences CentreOntarioTorontoCanada
| | - Maneesh Sud
- Temerty Faculty of MedicineUniversity of TorontoOntarioTorontoCanada,Institute for Health Policy, Management, and EvaluationOntarioTorontoCanada,Division of Cardiology, Department of MedicineSchulich Heart Program, Sunnybrook Health Sciences CentreOntarioTorontoCanada
| | - Derrick Y. Tam
- Temerty Faculty of MedicineUniversity of TorontoOntarioTorontoCanada,Institute for Health Policy, Management, and EvaluationOntarioTorontoCanada,Division of Cardiac Surgery, Department of SurgerySchulich Heart Program, Sunnybrook Health Sciences CentreOntarioTorontoCanada
| | - Mina Madan
- Temerty Faculty of MedicineUniversity of TorontoOntarioTorontoCanada,Division of Cardiology, Department of MedicineSchulich Heart Program, Sunnybrook Health Sciences CentreOntarioTorontoCanada
| | - Gil Marcus
- Division of Cardiology, Department of MedicineSchulich Heart Program, Sunnybrook Health Sciences CentreOntarioTorontoCanada
| | | | - Mamas A. Mamas
- Keele Cardiovascular Research GroupKeele UniversityKeeleUnited Kingdom
| | - Harindra C. Wijeysundera
- Temerty Faculty of MedicineUniversity of TorontoOntarioTorontoCanada,Institute for Health Policy, Management, and EvaluationOntarioTorontoCanada,Institute for Clinical Evaluative SciencesOntarioTorontoCanada,Division of Cardiology, Department of MedicineSchulich Heart Program, Sunnybrook Health Sciences CentreOntarioTorontoCanada,Sunnybrook Research InstituteOntarioTorontoCanada
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Patel RV, Ravindran M, Manoragavan R, Sriharan A, Wijeysundera HC. Risk Factors for Hospital Readmission Post-Transcatheter Aortic Valve Implantation in the Contemporary Era: A Systematic Review. CJC Open 2022; 4:792-801. [PMID: 36148255 PMCID: PMC9486870 DOI: 10.1016/j.cjco.2022.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 05/31/2022] [Indexed: 11/24/2022] Open
Abstract
Background Despite transcatheter aortic valve implantation (TAVI) becoming a widely accepted therapeutic option for the management of aortic stenosis, post-procedure readmission rates remain high. Rehospitalization is associated with negative patient outcomes, as well as increased healthcare costs, and has therefore been identified as an important target for quality improvement. Strategies to reduce the post-TAVI readmission rate are needed but require the identification of patients at high risk for rehospitalization. Our systematic review aims to identify predictors of post-procedure readmission in patients eligible for TAVI. Methods We conducted a comprehensive search of the MEDLINE, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) databases for the time period from 2015 to the present for articles evaluating risk factors for rehospitalization post-TAVI with a follow-up period of at least 30 days in adults age ≥ 70 years with aortic stenosis. The quality of included studies was evaluated using the Newcastle-Ottawa Scale. We present the results as a qualitative narrative review. Results We identified 49 studies involving 828,528 patients. Post-TAVI readmission is frequent, and rates vary (14.9% to 54.3% at 1 year). The most-frequent predictors identified for both 30-day and 1-year post-TAVI readmission are atrial fibrillation, lung disease, renal disease, diabetes mellitus, in-hospital life-threatening bleeding, and non-femoral access. Conclusions This systematic review identifies the most-common predictors for 30-day and 1-year readmission post-TAVI, including comorbidities and potentially modifiable procedural approaches and complications. These predictors can be used to identify patients at high-risk for readmission who are most likely to benefit from increased support and follow-up post-TAVI.
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Miranda RN, Qiu F, Manoragavan R, Fremes S, Lauck S, Sun L, Tarola C, Tam DY, Mamas M, Wijeysundera HC. Drivers and outcomes of variation in surgical versus transcatheter aortic valve replacement in Ontario, Canada: a population-based study. Open Heart 2022; 9:openhrt-2021-001881. [PMID: 35101899 PMCID: PMC8804707 DOI: 10.1136/openhrt-2021-001881] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 01/09/2022] [Indexed: 12/21/2022] Open
Abstract
Objectives To understand the patient and hospital level drivers of the variation in surgical versus trascatheter aortic valve replacement (SAVR vs TAVR) for patients with aortic stenosis (AS) and to explore whether this variation translates into differences in clinical outcomes. Background Adoption of TAVR has grown exponentially worldwide. Notwithstanding, a wide variation in TAVR rates has been seen within and between countries and in some jurisdictions AS is still primarily being managed by SAVR. Methods We conducted a population-based retrospective cohort study in Ontario, Canada, including individuals who received TAVR or SAVR between 2016 and 2020. We developed iterative hierarchical logistic regression models for the likelihood of receiving TAVR instead of SAVR examining sequentially patient characteristics, hospital factors and year of procedure, calculating the median ORs and variance partition coefficients for each. Using Cox proportional hazards models, we examined the relationship between TAVR/SAVR ratio on all-cause mortality and readmissions. Results Annual procedures rates per million population increased from 171 to 201, mainly driven by the expansion of TAVR. TAVR/SAVR ratios differed substantially between hospitals, from 0.21 to 3.27. Neither patient nor hospital factors explained the between-hospital variation in AS treatment. The TAVR/SAVR ratio was significantly associated with clinical outcomes with high ratio hospitals having lower mortality and rehospitalisations. Conclusions Despite the expansion of TAVR, dramatic variation exists that is not explained by patient or hospital factors. This variation was associated with differences in clinical outcomes, suggesting that further work is needed in understanding and addressing inequity of access.
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Affiliation(s)
- Rafael N Miranda
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, Toronto, Ontario, Canada
| | - Feng Qiu
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Ragavie Manoragavan
- Schulich Heart Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Stephen Fremes
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Schulich Heart Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Sandra Lauck
- Centre for Heart Valve Innovation, Saint Paul's Hospital, Vancouver, British Columbia, Canada
| | - Louise Sun
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Division of Cardiac Anesthesiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Christopher Tarola
- Schulich Heart Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Derrick Y Tam
- Schulich Heart Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Mamas Mamas
- Keele Cardiovascular Research Group, School of Medicine, Keele University, Keele, UK
| | - Harindra C Wijeysundera
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Schulich Heart Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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9
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Marcus G, Qiu F, Manoragavan R, Ko DT, Elbaz-Greener G, Chung JCY, Sud M, Farkouh ME, Madan M, Fremes SE, Wijeysundera HC. Temporal Trends and Drivers of Heart Team Utilization in Transcatheter Aortic Valve Replacement: A Population-Based Study in Ontario, Canada. J Am Heart Assoc 2021; 10:e020741. [PMID: 34155897 PMCID: PMC8403321 DOI: 10.1161/jaha.120.020741] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The multidisciplinary Heart Team (HT) is recommended for management decisions for transcatheter aortic valve replacement (TAVR) candidates, and during TAVR procedures. Empiric evidence to support these recommendations is limited. We aimed to explore temporal trends, drivers, and outcomes associated with HT utilization. Methods and Results TAVR candidates were identified in Ontario, Canada, from April 1, 2012 to March 31, 2019. The HT was defined as having a billing code for both a cardiologist and cardiac surgeon during the referral period. The procedural team was defined as a billing code during the TAVR procedure. Hierarchical logistical models were used to determine the drivers of HT. Median odds ratios were calculated to quantify the degree of variation among hospitals. Of 10 412 patients referred for TAVR consideration, 5489 (52.7%) patients underwent a HT during the referral period, with substantial range between hospitals (median odds ratio of 1.78). Utilization of a HT for TAVR referrals declined from 69.9% to 41.1% over the years of the study. Patient characteristics such as older age, frailty and dementia, and hospital characteristics including TAVR program size, were found associated with lower HT utilization. In TAVR procedures, the procedural team included both cardiologists and cardiac surgeons in 94.9% of cases, with minimal variation over time or between hospitals. Conclusions There has been substantial decline in HT utilization for TAVR candidates over time. In addition, maturity of TAVR programs was associated with lower HT utilization.
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Affiliation(s)
- Gil Marcus
- Schulich Heart Program Division of Cardiology Sunnybrook Health Sciences Centre University of Toronto Ontario Canada
| | | | - Ragavie Manoragavan
- Schulich Heart Program Division of Cardiology Sunnybrook Health Sciences Centre University of Toronto Ontario Canada
| | - Dennis T Ko
- Schulich Heart Program Division of Cardiology Sunnybrook Health Sciences Centre University of Toronto Ontario Canada.,ICES Toronto Ontario Canada.,Institute for Health Policy Management and Evaluation University of Toronto Ontario Canada
| | - Gabby Elbaz-Greener
- Department of Cardiology Hadassah Medical Center Jerusalem Israel.,Faculty of Medicine Hebrew University of Jerusalem Israel
| | - Jennifer C Y Chung
- Division of Cardiovascular Surgery Department of Surgery Peter Munk Cardiac Centre University Health NetworkUniversity of Toronto Ontario Canada
| | - Maneesh Sud
- Schulich Heart Program Division of Cardiology Sunnybrook Health Sciences Centre University of Toronto Ontario Canada.,ICES Toronto Ontario Canada.,Institute for Health Policy Management and Evaluation University of Toronto Ontario Canada
| | - Michael E Farkouh
- Peter Munk Cardiac Centre and Heart and Stroke Richard Lewar Centre University of Toronto Canada
| | - Mina Madan
- Schulich Heart Program Division of Cardiology Sunnybrook Health Sciences Centre University of Toronto Ontario Canada
| | - Stephen E Fremes
- Schulich Heart Program Division of Cardiac Surgery Sunnybrook Health Sciences Centre University of Toronto Ontario Canada
| | - Harindra C Wijeysundera
- Schulich Heart Program Division of Cardiology Sunnybrook Health Sciences Centre University of Toronto Ontario Canada.,ICES Toronto Ontario Canada.,Institute for Health Policy Management and Evaluation University of Toronto Ontario Canada
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10
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Sunner M, Qiu F, Manoragavan R, Roifman I, Tam DY, Fremes SC, Sun L, Rahal M, Woodward G, Austin PC, Wijeysundera HC. Predictors of cumulative cost for patients with severe aortic stenosis referred for surgical or transcatheter aortic valve replacement: a population-based study in Ontario, Canada. Eur Heart J Qual Care Clin Outcomes 2020; 7:265-272. [PMID: 33351143 DOI: 10.1093/ehjqcco/qcaa094] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 11/29/2020] [Accepted: 12/10/2020] [Indexed: 11/13/2022]
Abstract
AIMS Transcatheter aortic valve replacement (TAVR) as an alternative to surgical aortic valve replacement (SAVR) has transformed severe aortic stenosis (AS) management. Our aim was understand AS cost drivers from referral to 1-year post-procedure. METHODS AND RESULTS We identified patients referred for either TAVR/SAVR between 1 April 2015 and 31 March 2018, with follow-up until 31 March 2019 in Ontario, Canada. We stratified costs into (i) a referral phase, (ii) a procedural phase from the procedure date to 60 days post-procedure, and (iii) post-procedure phase from 61 days to 1 year. Multivariable regression modelling using generalized linear models with a log link gamma distribution was used to identify cost drivers in each phase. The study cohort included 12 086 AS patients; 4832 were referred for TAVR and 7254 were referred for SAVR. The median cost for TAVR was higher than SAVR in the referral ($3593 vs. $2944) and post-procedural ($5938 vs. $3257) phases. In contrast, for the procedural phase, SAVR had a median cost of $29 756 vs. $27 907 for TAVR. Predictors of high cost in the referral phase were longer wait-time, and an urgent in-hospital procedure. In the procedural phase, procedural complications were the major drivers of higher cost. In the post-procedural phase, patient co-morbidities were the major drivers, specifically dialysis, liver disease, cancer, peripheral vascular disease, and diabetes mellitus. CONCLUSION We identified distinct patterns of cost accumulation and modifiable drivers for SAVR compared with TAVR; these drivers may guide clinical and health policy decisions to make AS care more efficient.
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Affiliation(s)
- Manjot Sunner
- Division of Cardiology, Department of Medicine, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave., Room A202, Toronto, Ontario M4N 3M5, Canada
| | | | - Ragavie Manoragavan
- Division of Cardiology, Department of Medicine, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave., Room A202, Toronto, Ontario M4N 3M5, Canada
| | - Idan Roifman
- Division of Cardiology, Department of Medicine, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave., Room A202, Toronto, Ontario M4N 3M5, Canada
| | - Derrick Y Tam
- Division of Cardiac Surgery, Department of Surgery, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Stephen C Fremes
- Division of Cardiac Surgery, Department of Surgery, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Louise Sun
- ICES, Toronto, Ontario, Canada.,Division of Cardiac Anesthesiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | | | | | - Peter C Austin
- ICES, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Harindra C Wijeysundera
- Division of Cardiology, Department of Medicine, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave., Room A202, Toronto, Ontario M4N 3M5, Canada.,ICES, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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11
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Ravindran M, Henning KA, Qiu F, Manoragavan R, Dvir D, Shuvy M, Sud MK, Wijeysundera HC. Predictors of Long-term Cardiovascular Versus Non-cardiovascular Mortality and Repeat Intervention in Patients Having Transcatheter Aortic Valve Implantation. Am J Cardiol 2020; 135:105-112. [PMID: 32866442 DOI: 10.1016/j.amjcard.2020.08.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 08/13/2020] [Accepted: 08/17/2020] [Indexed: 11/26/2022]
Abstract
There is a paucity of literature characterizing the risk of long-term mortality and reintervention after transcatheter aortic valve implantation (TAVI). Addressing this gap has become increasingly relevant with the inclusion of intermediate and low surgical risk patients and the need for data to inform their long-term management. We sought to investigate the long-term trends and predictors of cardiovascular versus noncardiovascular mortality as well as reintervention in post-TAVI patients. Our cohort consisted of 5,406 patients who underwent TAVI in Ontario, Canada from 2011 to 2018. We used Kaplan-Meier analysis to estimate 7-year all-cause mortality and a Cox proportional hazard model to identify demographic, co-morbid, and procedural predictors. Similarly, cumulative incidence functions were used to estimate cardiovascular versus noncardiovascular mortality at 5 years, with predictors identified through Fine-Gray models. The Kaplan-Meier estimate for 7-year all-cause mortality in our cohort was 67%; this was driven by a number of co-morbidities including congestive heart failure and liver disease. We found that cardiovascular death was more likely for approximately the first 2 years post-TAVI whereas noncardiovascular death was more likely from this point to the end of the study. We identified a number of factors that uniquely modified the risk of either cardiovascular or noncardiovascular mortality. Only 1.6% of patients who underwent repeat intervention. The distinct factors associated with cardiovascular versus noncardiovascular death suggest different approaches to short-term and long-term surveillance of patients post-TAVI by both the heart team and primary care providers.
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12
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Ravindran M, Henning K, Qiu F, Manoragavan R, Dvir D, Shuvy M, Sud M, Wijeysundera H. PREDICTORS OF LONG-TERM CARDIOVASCULAR VERSUS NON-CARDIOVASCULAR MORTALITY AND REPEAT INTERVENTION IN TRANSCATHETER AORTIC VALVE REPLACEMENT. Can J Cardiol 2020. [DOI: 10.1016/j.cjca.2020.07.081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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