Interventional cardiology

Determining TAVR excellence: what to expect in 2017

Dr. By Dharam Kumbhani
Dr. Dharam Kumbhani

By Dharam Kumbhani, M.D.
Assistant Professor of Internal Medicine

I was pleased to moderate several discussions at the AHA Scientific Sessions focused on the future of transcatheter aortic valve replace­ment (TAVR) heading into 2017. I’m Co-Chair and a member of several national committees that contribute to writing TAVR guidelines and advise medical societies on the procedure. One of the biggest discussions right now is how many TAVR sites we need in the United States. 

There are more than 1,000 cardiac surgi­cal programs in the U.S. As of November 2016, nearly half of them were TAVR centers. TAVR is a complex procedure, and the patients who need it are complex patients. Cardiology societies are tasked with determining how to ensure patients’ access to TAVR without compromising quality of the procedure.

Today, hospitals must jump through multiple hoops to become TAVR sites. I’m researching the structural metrics for designating hospitals as high-performing centers for procedures such as TAVR. One of the most commonly used metrics is hospital volume. This is felt to be a good sur­rogate for quality of care. For instance, for CMS to reimburse hospitals to do TAVR, they should be performing at least 50 surgical valve replace­ments annually.

There is also a move to designate higher-volume hospitals as valve centers of excellence. However, volume doesn’t have a linear correlation with quality. My research indicates that using volume alone to designate aortic and mitral valve surgical hospitals as high or low performing has the potential to misclassify nearly a quarter of all hospitals that perform valve surgery in the U.S.

Thus, it makes sense to try and figure out other metrics that can be used to supplement volume benchmarks for TAVR and other valve surgeries. Systems of care appear to be more important, and it is my belief that hospitals can have good outcomes with strong care systems in place even while treating a lower volume of patients. Ultimately, the focus for evaluating quality delivered by hospitals should be on concrete outcomes, both short-term and long-term, rather than on surrogate benchmarks alone. 

“One of the biggest discussions right now is how many TAVR sites we need in the United States. There are more than 1,000 cardiac surgical programs in the U.S. As of November 2016, nearly half of them were TAVR centers.”


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