Metric loss

“Home time” validated as a performance measure of TAVI results

Patients who were alive and healthy at home during the first 30 days had lower mortality and readmission than those with longer stays.

More days spent at home within 30 days after TAVI, rather than in a hospital or care facility, is a predictor of lower mortality and readmission rates over time, a new study suggests. Used as an outcome measure, time spent at home could complement other currently used measures of hospital performance, such as TAVI volume, the researchers said.

An important characteristic of time spent at home is that it is easily understood by patients and that it is more intuitive than other measures to assess hospital performance, Lead author Amgad Mentias, MD (Cleveland Clinic Foundation, OH), told TCTMD in an email. Previously, the 30-day home time metric had been shown to be a strong predictor of mortality and readmission in patients with heart failure and acute MI, but it had not been tested in TAVI care .

In their study, published on January 10, 2022, in the Journal of the American College of Cardiology, Mentias and colleagues found that 30-day and 1-year mortality and readmission were inversely correlated with risk-adjusted 30-day stay in residence.

Knowing the home time after TAVR for a specific hospital brings this patient-centered approach to the forefront and helps clinicians and hospitals strive for care that leads to improved outcomes that are most significant for the patient. patients, ”noted Mentias.

In an accompanying editorial, Matthew W. Sherwood, MD (Inova Heart and Vascular Institute, Falls Church, VA) and Amit N. Vora, MD (University of Pennsylvania Medical Center Heart and Vascular Institute, Harrisburg, PA), agree that the time house is “a simple, transparent, intuitive metric which is understandable both for institutions and for patients”. Going forward, they add, “stakeholders from the provider and patient domains should be brought together to establish composite metrics (including new metrics such as 30-day home time) that better align healthcare needs. all parties”.

Mentias et al assessed the outcomes of 160,792 Medicare patients from 652 centers who underwent elective TAVI between 2015 and 2019. Hospitals were stratified into quartiles by risk-adjusted 30-day home time. Quartile 1 (Q1) represented the worst performing hospitals and quartile 4 (Q4) the best performing.

The increase in time spent at home at 30 days is correlated with lower in-hospital mortality (Q1: 1.40% vs Q4: 0.76%), 30-day mortality (Q1: 2.31% against Q4: 1.37%), readmission at 30 days (Q1: 14.36% vs Q4: 10.80% and composite clinical result at 30 days (Q1: 4.94%, Q4: 3.56%; P P

The length of hospital stay after TAVI (46.4%) and stay in a skilled nursing facility (25.4%) were the most common reasons for lost days of time at home during the 30 day period. According to the authors, patients who waste time at home for these reasons are likely those with a high burden of co-morbidities, poor functional status, and an increased burden of frailty. Individual TAVI volume was not significantly correlated with risk-adjusted 30-day home time (P = 0.90).

In all centers, time spent at home as a measure has resulted in a change and reclassification of the performance status of some hospitals: improving some, while downgrading others.

Incentive and downstream consequences

At TCTMD, Mentias said no only one metric is perfect, including this one, which is why he considers it complementary.

When hospital performance is assessed using multiple metrics, we get a better picture of overall care and the limitations of one metric can be covered by the other, ”he said.

There is a theoretical risk that time spent at home may prompt some hospitals to perform TAVI preferably in low-risk patients or to refer patients home who might benefit from skilled nursing facilities or acute care centers. long term. However, Mentis said the holistic nature of the metric used with others “would deter such approaches as they would lead to higher chances of readmission or unwanted outcomes that contribute to wasted time at home.” Instead, he and his colleagues believe that using the metric might actually make TAVI centers more judicious in using these types of facilities, potentially partnering with top performers to ensure continuity. quality care.

“As with any outcome measure, it will be important to monitor progress and continually refine the metric to achieve stated goals and minimize unwarranted downstream consequences,” warn Sherwood and Vora. What is concerning is growing evidence that strong public reporting on hospital parameters contributes to risk aversion among some operators.

“If this practice model were translated into TAVR, there could be significant consequences for the elderly and access to care for fragile patients,” they add.