Racial/Ethnic Disparities in Aortic Valve Replacement Among Medicare Beneficiaries in the United States, 2012-2019.

PURPOSE: There are concerns that transcatheter or surgical aortic valve replacement (TAVR/SAVR) procedures are preferentially available to White patients. Our objective was to examine differences in utilization of aortic valve replacement and outcomes by race/ethnicity in the US for patients with aortic stenosis. METHODS: We performed a serial cross-sectional cohort study of 299,976 Medicare beneficiaries hospitalized with principal diagnosis of aortic stenosis between 2012 and 2019 stratified by self-reported race/ethnicity (Black, Hispanic, Asian, Native American, and White). Outcomes included aortic valve replacement rates within 6 months of index hospitalization and associated procedural outcomes, including 30-day readmission, 30-day and 1-year mortality. RESULTS: Within 6 months of an index admission for aortic stenosis, 86.8% (122,457 SAVR; 138,026 TAVR) patients underwent aortic valve replacement. Overall, compared with White people, Black (HR 0.87 [0.85-0.89]), Hispanic (0.92 [0.88-0.96]), and Asian (0.95 [0.91-0.99]) people were less likely to receive aortic valve replacement. Among patients who were admitted emergently/urgently, White patients (41.1%, 95% CI, 40.7-41.4) had a significantly higher aortic valve replacement rate compared with Black (29.6%, 95% CI, 28.3-30.9), Hispanic (36.6%, 95% CI, 34.0-39.3), and Asian patients (35.4%, 95% CI, 32.3-38.9). Aortic valve replacement rates increased annually for all race/ethnicities. There were no significant differences in 30-day or 1-year mortality by race/ethnicity. CONCLUSIONS: Aortic valve replacement rates within 6 months of aortic stenosis admission are lower for Black, Hispanic, and Asian people compared to White people. These race-related differences in aortic stenosis treatment reflect complex issues in diagnosis and management, warranting a comprehensive reassessment of the entire care spectrum for disadvantaged populations.

Assessment of online information on robotic cardiac and thoracic surgery.

Online health resources are important for patients seeking perioperative information on robotic cardiac and thoracic surgery. The value of the resources depends on their readability, accuracy, content, quality, and suitability for patient use. We systematically assess current online health information on robotic cardiac and thoracic surgery. Systematic online searches were performed to identify websites discussing robotic cardiac and thoracic surgery. For each website, readability was measured by nine standardized tests, and accuracy and content were assessed by an independent panel of two robotic cardiothoracic surgeons. Quality and suitability of websites were evaluated using the DISCERN and Suitability Assessment of Materials tools, respectively. A total of 220 websites (120 cardiac, and 100 thoracic) were evaluated. Both robotic cardiac and thoracic surgery websites were very difficult to read with mean readability scores of 13.8 and 14.0 (p = 0.97), respectively, requiring at least 13 years of education to be comprehended. Both robotic cardiac and thoracic surgery websites had similar accuracy, amount of content, quality, and suitability (p > 0.05). On multivariable regression, academic websites [Exp (B)], 2.25; 95% confidence interval [CI], 1.60-3.16; P < 0.001), and websites with higher amount of content [Exp (B)],1.73; 95% CI, 1.24-2.41; P < 0.001) were associated with higher accuracy. There was no association between readability of websites and accuracy [Exp (B)], 1.04; 95% CI, 0.90-1.21; P = 0.57). Online information on robotic cardiac and thoracic surgery websites overestimate patients' understanding and require at least 13 years of education to be comprehended. As website accuracy is not associated with ease of reading, the readability of online resources can be improved without compromising accuracy.

Widening volume and persistent outcome disparity in valve operations: New York statewide analysis, 2005-2016.

OBJECTIVES: Volume concentration of complex noncardiac operations to high-volume centers has been observed, but whether this is also occurring in cardiac surgery is unknown. We examined the relationship between volume concentration and mortality rates for valve surgery and coronary artery bypass grafting (CABG) between 2005 and 2016 in New York State. METHODS: We analyzed publicly available, hospital-level case volume and risk-adjusted mortality rates (RAMRs) from 2005 to 2016 for isolated CABG and isolated or concomitant valve operations performed in New York. We identified hospitals in the top- and bottom-volume quartiles for each procedure type and compared changes in percent market share and outcomes. Bivariate and univariate longitudinal analysis was used to evaluate the statistical significance of the temporal trend. RESULTS: Among 36 centers, percent market share of the top-volume quartile increased for valve cases from 54.4% to 59.4%, whereas CABG share increased from 41.4% to 44.3%. No significant changes were noted in market share for the bottom quartile. The top-volume quartile demonstrated significant trends in improving outcomes over the study period for both valve procedures (RAMR: -0.261%/year, P < .001) and CABG (RAMR: -0.071%/year, P = .018). No significant trends were noted in the bottom quartile for either procedure. CONCLUSIONS: In New York, over the last decade, highest-volume hospitals increased their market share for valve operations while maintaining lower mortality rates than lowest-volume hospitals. Valve volume is regionalizing in the setting of a persistent outcome gap between the highest- and lowest-volume hospitals, suggesting that volume-based referrals for specialized cardiac procedures may improve surgical mortality.

Trends in Transcatheter and Surgical Aortic Valve Replacement Among Older Adults in the United States.

BACKGROUND: Recent trends, including survival beyond 30 days, in aortic valve replacement (AVR) following the expansion of indications for transcatheter aortic valve replacement (TAVR) are not well-understood. OBJECTIVES: The authors sought to characterize the trends in characteristics and outcomes of patients undergoing AVR. METHODS: The authors analyzed Medicare beneficiaries who underwent TAVR and SAVR in 2012 to 2019. They evaluated case volume, demographics, comorbidities, 1-year mortality, and discharge disposition. Cox proportional hazard models were used to assess the annual change in outcomes. RESULTS: Per 100,000 beneficiary-years, AVR increased from 107 to 156, TAVR increased from 19 to 101, whereas SAVR declined from 88 to 54. The median [interquartile range] age remained similar from 77 [71-83] years to 78 [72-84] years for overall AVR, decreased from 84 [79-88] years to 81 [75-86] years for TAVR, and decreased from 76 [71-81] years to 72 [68-77] years for SAVR. For all AVR patients, the prevalence of comorbidities remained relatively stable. The 1-year mortality for all AVR decreased from 11.9% to 9.4%. Annual change in the adjusted odds of 1-year mortality was 0.93 (95% CI: 0.92-0.94) for TAVR and 0.98 (95% CI: 0.97-0.99) for SAVR, and 0.94 (95% CI: 0.93-0.95) for all AVR. Patients discharged to home after AVR increased from 24.2% to 54.7%, primarily driven by increasing home discharge after TAVR. CONCLUSIONS: The advent of TAVR has led to about a 60% increase in overall AVR in older adults. Improving outcomes in AVR as a whole following the advent of TAVR with increased access is a reassuring trend.

Evaluation of Racial and Ethnic Disparities in Cardiac Transplantation.

Background Racial and ethnic disparities contribute to differences in access and outcomes for patients undergoing heart transplantation. We evaluated contemporary outcomes for heart transplantation stratified by race and ethnicity as well as the new 2018 allocation system. Methods and Results Adult heart recipients from 2011 to 2020 were identified in the United Network for Organ Sharing database and stratified into 3 groups: Black, Hispanic, and White. We analyzed recipient and donor characteristics, and outcomes. Among 32 353 patients (25% Black, 9% Hispanic, 66% White), Black and Hispanic patients were younger, more likely to be women and have diabetes mellitus or renal disease (all, P<0.05). Over the study period, the proportion of Black and Hispanic patients listed for transplant increased: 21.7% to 28.2% (P=0.003) and 7.7% to 9.0% (P=0.002), respectively. Compared with White patients, Black patients were less likely to undergo transplantation (adjusted hazard ratio [aHR], 0.87; CI, 0.84-0.90; P<0.001), but had a higher risk of post-transplant death (aHR, 1.14; CI, 1.04-1.24; P=0.004). There were no differences in transplantation likelihood or post-transplant mortality between Hispanic and White patients. Following the allocation system change, transplantation rates increased for all groups (P<0.05). However, Black patients still had a lower likelihood of transplantation than White patients (aHR, 0.90; CI, 0.79-0.99; P=0.024). Conclusions Although the proportion of Black and Hispanic patients listed for cardiac transplantation have increased, significant disparities remain. Compared with White patients, Black patients were less likely to be transplanted, even with the new allocation system, and had a higher risk of post-transplantation death.

Administrative Claims Measure for Profiling Hospital Performance Based on 90-Day All-Cause Mortality Following Coronary Artery Bypass Graft Surgery.

BACKGROUND: Coronary artery bypass graft (CABG) surgery is a focus of bundled and alternate payment models that capture outcomes up to 90 days postsurgery. While clinical registry risk models perform well, measures encompassing mortality beyond 30 days do not currently exist. We aimed to develop a risk-adjusted hospital-level 90-day all-cause mortality measure intended for assessing hospital performance in payment models of CABG surgery using administrative data. METHODS: Building upon Centers for Medicare and Medicaid Services hospital-level 30-day all-cause CABG mortality measure specifications, we extended the mortality timeframe to 90 days after surgery and developed a new hierarchical logistic regression model to calculate hospital risk-standardized 90-day all-cause mortality rates for patients hospitalized for isolated CABG. The model was derived from Medicare claims data for a 3-year cohort between July 2014 to June 2017. The data set was randomly split into 50:50 development and validation samples. The model performance was evaluated with C statistics, overfitting indices, and calibration plot. The empirical validity of the measure result at the hospital level was evaluated against the Society of Thoracic Surgeons composite star rating. RESULTS: Among 137 819 CABG procedures performed in 1183 hospitals, the unadjusted mortality rate within 30 and 90 days were 3.1% and 4.7%, respectively. The final model included 27 variables. Hospital-level 90-day risk-standardized mortality rates ranged between 2.04% and 11.26%, with a median of 4.67%. C statistics in the development and validation samples were 0.766 and 0.772, respectively. We identified a strong positive correlation between 30- and 90-day risk-standardized mortality rates, with a regression slope of 1.09. Risk-standardized mortality rates also showed a stepwise trend of lower 90-day mortality with higher Society of Thoracic Surgeons composite star ratings. CONCLUSIONS: We present a measure of hospital-level 90-day risk-standardized mortality rates following isolated CABG. This measure complements Centers for Medicare and Medicaid Services' existing 30-day CABG mortality measure by providing greater insight into the postacute recovery period. It offers a balancing measure to ensure efforts to reduce costs associated with CABG recovery and rehabilitation do not result in unintended consequences.

Trends in Reoperative Coronary Artery Bypass Graft Surgery for Older Adults in the United States, 1998 to 2017.

Background The likelihood of undergoing reoperative coronary artery bypass graft surgery (CABG) is important for older patients who are considering first-time CABG. Trends in the reoperative CABG for these patients are unknown. Methods and Results We used the Medicare fee-for-service inpatient claims data of adults undergoing isolated first-time CABG between 1998 and 2017. The primary outcome was time to first reoperative CABG within 5 years of discharge from the index surgery, treating death as a competing risk. We fitted a Cox regression to model the likelihood of reoperative CABG as a function of patient baseline characteristics. There were 1 666 875 unique patients undergoing first-time isolated CABG and surviving to hospital discharge. The median (interquartile range) age of patients did not change significantly over time (from 74 [69-78] in 1998 to 73 [69-78] in 2017); the proportion of women decreased from 34.8% to 26.1%. The 5-year rate of reoperative CABG declined from 0.77% (95% CI, 0.72%-0.82%) in 1998 to 0.23% (95% CI, 0.19%-0.28%) in 2013. The annual proportional decline in the 5-year rate of reoperative CABG overall was 6.6% (95% CI, 6.0%-7.1%) nationwide, which did not differ across subgroups, except the non-white non-black race group that had an annual decline of 8.5% (95% CI, 6.2%-10.7%). Conclusions Over a recent 20-year period, the Medicare fee-for-service patients experienced a significant decline in the rate of reoperative CABG. In this cohort of older adults, the rate of declining differed across demographic subgroups.

Evaluation of Case Volumes of a Heart Transplant Program and Short-term Outcomes After Changes in the United Network for Organ Sharing Donor Heart Allocation System.

Importance: Institution-level strategic changes may be associated with heart transplant volume and outcomes. Objective: To describe changes in practice that markedly increased heart transplant volume at a single center, as well as associated patient characteristics and outcomes. Design, Setting, and Participants: A pre-post cohort study was conducted of 107 patients who underwent heart transplant between September 1, 2014, and August 31, 2019, at Yale New Haven Hospital before (September 1, 2014, to August 31, 2018; prechange era) and after (September 1, 2018, to August 31, 2019; postchange era) a strategic change in patient selection by the heart transplant program. Exposure: Strategic change in donor and recipient selection at Yale New Haven Hospital that occurred in August 2018. Main Outcomes and Measures: Outcome measures were transplant case volume, donor and recipient characteristics, and 180-day survival. Results: A total of 49 patients (12.3 per year; 20 women [40.8%]; median age, 57 years [interquartile range {IQR}, 50-63 years]) received heart transplants in the 4 years of the prechange era and 58 patients (58 per year; 19 women [32.8%]; median age, 57 years [IQR, 52-64 years]) received heart transplants in the 1 year of the postchange era. Organ offers were more readily accepted in the postchange era, with an offer acceptance rate of 20.5% (58 of 283) compared with 6.4% (49 of 768) in the prechange era (P < .001). In the postchange era, donor hearts were accepted with a higher median number of prior refusals by other centers than in the prechange era (16.5 [IQR, 6-38] vs 3 [IQR, 1-6]; P < .001). Hearts accepted in the postchange era were from older donors than in the prechange era (median age, 40 years [IQR, 29-48 years] vs 30 years [IQR, 24-42 years]; P < .001). Recipients had a significantly shorter time on the waiting list in the postchange era compared with prechange era (median, 41 days [IQR, 12-289 days] vs 242 days [IQR, 135-428 days]; P < .001). More patients were supported on temporary circulatory assist devices preoperatively in the postchange era than the prechange era (14 [24.1%] vs 0; P < .001). Survival rates at 180 days were not significantly different (43 [87.8%] in the prechange era vs 52 [89.7%] in the postchange era). Mortality while on the waiting list was similar (2.8 deaths per year in the prechange era vs 3 deaths per year in the postchange era). During the comparable time period, 4 other regional centers had volume change ranging from -10% to 68%, while this center's volume increased by 374%. Conclusions and Relevance: This study suggests that strategic changes in donor heart and recipient selection may significantly increase the number of heart transplants while maintaining short-term outcomes comparable with more conservative patient selection. Such an approach may augment the allocation of currently unused donor hearts.

[Early outcome of surgical aortic valve replacement for aortic stenosis in Icelandic females].

INTRODUCTION: Aortic valve replacement (AVR) for aortic stenosis (AS) is the second most common open-heart procedure performed in Iceland. The aim of this study was to analyze the early outcome of AVR among females in Iceland. MATERIALS AND METHODS: This was a retrospective study including 428 patients who underwent surgical AVR due to AS in Iceland from 2002-2013. Information was gathered from medical records, including pre- and postoperative results of echocardiography and complications. Overall survival was estimated (Kaplan-Meier) and logistic regression used to identify predictors of operative mortality. The median follow-up time was 8.8 years (0-16.5 years). RESULTS: Of the 428 patients, 151 were female (35.3%), that were on average 2 years older than men (72.6 ± 9.4 vs. 70.4 ± 9.8 yrs., p=0.020). Preoperative symptoms were similar, but women had significantly higher EurosSCORE II than men (5.2 ± 8.8 vs. 3.2 ± 4.6, p=0.002). Maximal pressure-gradient across the aortic valve was higher for women (74.4 ± 29.3 mmHg vs. 68.0 ± 23.4 mmHg, p=0,013) but postoperative complications, operative mortality (8.6% vs. 4.0%, p=0.068) and 5-year survival (78.6% vs. 83.1%, p=0.245) were comparable for women and men. Logistic regression analysis showed that female gender was not an independent predictor of 30-day mortality (OR 1.54, 95% CI 0.63-3.77). CONCLUSIONS: Females constitute one third of patients that undergo AVR for AS in Iceland. At the time of surgery females are two years older than men and appear to have a more significant aortic stenosis at the time of surgery. However, complication rates, operative mortality and long-term survival were comparable for both genders.

Sex and Race Differences in the Utilization and Outcomes of Coronary Artery Bypass Grafting Among Medicare Beneficiaries, 1999-2014.

BACKGROUND: With over a decade of directed efforts to reduce sex and racial differences in coronary artery bypass grafting (CABG) utilization, and post-CABG outcomes, we sought to evaluate how the use of CABG and its outcomes have evolved in different sex and racial subgroups. METHODS AND RESULTS: Using data on all fee-for-service Medicare beneficiaries undergoing CABG in the United States from 1999 to 2014, we examined differences by sex and race in calendar-year trends for CABG utilization and post-CABG outcomes (in-hospital, 30-day, and 1-year mortality and 30-day readmission). A total of 1 863 719 Medicare fee-for-service beneficiaries (33.6% women, 4.6% black) underwent CABG from 1999 to 2014, with a decrease from 611 to 245 CABG procedures per 100 000 person-years. Men compared with women and whites compared with blacks had higher CABG utilization, with declines in all subgroups. Higher post-CABG annual declines in mortality (95% confidence interval) were observed in women (in-hospital, -2.70% [-2.97, -2.44]; 30-day, -2.29% [-2.54, -2.04]; and 1-year mortality, -1.67% [-1.88, -1.46]) and blacks (in-hospital, -3.31% [-4.02, -2.60]; 30-day, -2.80% [-3.49, -2.12]; and 1-year mortality, -2.38% [-2.92, -1.84]), compared with men and whites, respectively. Mortality rates remained higher in women and blacks, but differences narrowed over time. Annual adjusted 30-day readmission rates remained unchanged for all patient groups. CONCLUSIONS: Women and black patients had persistently higher CABG mortality than men and white patients, respectively, despite greater declines over the time period. These findings indicate progress, but also the need for further progress.

Trends in aortic dissection hospitalizations, interventions, and outcomes among medicare beneficiaries in the United States, 2000-2011.

BACKGROUND: The epidemiology of aortic dissection (AD) has not been well described among older persons in the United States. It is not known whether advancements in AD care over the last decade have been accompanied by changes in outcomes. METHODS AND RESULTS: The Inpatient Medicare data from 2000 to 2011 were used to determine trends in hospitalization rates for AD. Mortality rates were ascertained through corresponding vital status files. A total of 32 057 initial AD hospitalizations were identified. The overall hospitalization rate for AD remained unchanged at 10 per 100 000 person-years. For 30-day and 1-year mortality associated with AD, the observed rate decreased from 31.8% to 25.4% (difference, 6.4%; 95% confidence interval [CI], 6.2-6.5; adjusted, 6.4%; 95% CI, 5.7-6.9) and from 42.6% to 37.4% (difference, 5.2%; 95% CI, 5.1-5.2; adjusted, 6.2%; 95% CI, 5.3-6.7), respectively. For patients undergoing surgical repair for type A dissections, the observed 30-day mortality decreased from 30.7% to 21.4% (difference, 9.3%; 95% CI, 8.3-10.2; adjusted, 7.3%; 95% CI, 5.8-7.8) and the observed 1-year mortality decreased from 39.9% to 31.6% (difference, 8.3%; 95% CI, 7.5-9.1%; adjusted, 8.2%; 95% CI, 6.7-9.1). The 30-day mortality decreased from 24.9% to 21% (difference, 3.9%; 95% CI, 3.5-4.2; adjusted, 2.9%; 95% CI, 0.7-4.4) and 1-year decreased from 36.4% to 32.5% (difference, 3.9%; 95% CI, 3.3-4.3; adjusted, 3.9%; 95% CI, 2.5-6.3) for surgical repair of type B dissection. CONCLUSIONS: Although AD hospitalization rates remained stable, improvement in mortality was noted, particularly in patients undergoing surgical repair.

Trends in aortic valve replacement for elderly patients in the United States, 1999-2011.

IMPORTANCE: There is a need to describe contemporary outcomes of surgical aortic valve replacement (AVR) as the population ages and transcatheter options emerge. OBJECTIVE: To assess procedure rates and outcomes of surgical AVR over time. DESIGN, SETTING, AND PARTICIPANTS: A serial cross-sectional cohort study of 82,755,924 Medicare fee-for-service beneficiaries undergoing AVR in the United States between 1999 and 2011. MAIN OUTCOMES AND MEASURES: Procedure rates for surgical AVR alone and with coronary artery bypass graft (CABG) surgery, 30-day and 1-year mortality, and 30-day readmission rates. RESULTS: The AVR procedure rate increased by 19 (95% CI, 19-20) procedures per 100,000 person-years over the 12-year period (P<.001), with an age-, sex-, and race-adjusted rate increase of 1.6% (95% CI, 1.0%-1.8%) per year. Mortality decreased at 30 days (absolute decrease, 3.4%; 95% CI, 3.0%-3.8%; adjusted annual decrease, 4.1%; 95% CI, 3.7%- 4.4%) per year and at 1 year (absolute decrease, 2.6%; 95% CI, 2.1%-3.2%; adjusted annual decrease, 2.5%; 95% CI, 2.3%-2.8%). Thirty-day all-cause readmission also decreased by 1.1% (95% CI, 0.9%-1.3%) per year. Aortic valve replacement with CABG surgery decreased, women and black patients had lower procedure and higher mortality rates, and mechanical prosethetic implants decreased, but 23.9% of patients 85 years and older continued to receive a mechanical prosthesis in 2011. CONCLUSIONS AND RELEVANCE: Between 1999 and 2011, the rate of surgical AVR for elderly patients in the United States increased and outcomes improved substantially. Medicare data preclude the identification of the causes of the findings and the trends in procedure rates and outcomes cannot be causally linked. Nevertheless, the findings may be a useful benchmark for outcomes with surgical AVR for older patients eligible for surgery considering newer transcatheter treatments.

Observational study of mortality risk stratification by ischemic presentation in patients with acute type A aortic dissection: the Penn classification.

BACKGROUND: Acute type A aortic dissection is a surgical emergency, with an operative mortality as high as 25%. Ischemia is a known predictor of mortality. We tested the efficacy of a classification system--the Penn classification, which is based on ischemic pattern at clinical presentation--to stratify operative mortality risk and identify high-risk groups of patients for further intervention and study. METHODS: In this prospective observational study, patients underwent a standard aortic dissection repair protocol at the University of Pennsylvania, Philadelphia, PA, from 1993 to 2004. Patients were classified as having no ischemia, branch vessel malperfusion with localized organ ischemia, generalized ischemia with circulatory collapse, with or without cardiac involvement, or a combination of localized and generalized ischemia. RESULTS: The cohort comprised 221 patients. The mean age was 61.6 (+/- 14.8) years and 66.5% were male. At presentation 57.9% of patients had no ischemia, 17.6% had localized ischemia, 15.4% had generalized ischemia, and 9.0% had both localized and generalized ischemia. Overall, 28 (12.7%) patients died during the perioperative period. All-cause mortality differed significantly between groups (no ischemia 3.1%, localized ischemia 25.6%, generalized ischemia 17.6%, combined ischemia 40.0%), yielding an overall 8.3-fold difference for no compared with any ischemia (3.1% versus 25.8%, P = 0.0001). Ischemic presentations together accounted for 85.7% of all deaths. CONCLUSION: The Penn classification of acute type A aortic dissection enabled stratification of patients by operative mortality risk. The system requires further validation, but might facilitate new ways to analyze mortality data for this disorder.