Metric loss

Time spent at home after TAVR – A new measure of hospital performance?

Time spent at home after transcatheter aortic valve replacement (TAVR) is important for patients, but can also provide a more comprehensive measure of hospital performance and quality of care, new research shows.

When researchers compared risk-adjusted time spent at home during the first 30 days after TAVI with the widely used hospital performance measure of annual volume of TAVI, performance was reclassified in 40% of hospitals.

Up to a fifth of hospitals were reclassified when time at home – defined as days spent alive at home outside a hospital or skilled nursing facility – was compared to readmission and death rates. 30-day risk-adjusted mortality.

“Our goal was to create a more patient-centric measure that was very comprehensive and incorporated both readmission and mortality into a single measure,” said lead author Ambarish Pandey, MD, MSCS, University of Texas Southwestern Medical Center, Dallas. | Medscape Cardiology.

The metric also recognizes that care for a patient with TAVR is not limited to a hospital setting, but may include time in a skilled nursing facility (SNF) or long-term acute care facility (LTAC), a he declared. “This must be taken into account and the entities providing this aspect of care must be held accountable.”

Researchers recently reported that time spent at home was a measure of hospital performance in cardiac arrest and myocardial infarction, but this is the first study to test its usefulness in TAVR, Pandey observed. The cohort included 160,792 Medicare beneficiaries who underwent elective TAVI at 652 centers from 2015 to 2019. The median annual volume of TAVI was 56 procedures.

Hospitals were stratified into 30-day risk-adjusted time-at-home quartiles, with high-performing hospitals (Q4) having fewer beds and slightly lower annual TAVI volume (43 vs. 54) than low-performing hospitals (Q1 ) but similar educational affiliation status and ownership.

Like reported this week in the Journal of the American College of Cardiology, the median 30-day hospital-level, risk-adjusted time at home – calculated from the day of TAVI – was 27.4 days (interquartile range: 26.3 – 28.5 days).

At 30 days, the median risk-adjusted mortality was 1.7% and the median risk-adjusted readmission rate was 12.6%.

Most of the time lost at home during the 30-day follow-up was the result of the index hospital stay (46.4%), followed by SNF stays (25.4%), hospital readmissions (16.6%) , deaths (8.2%) and LTAC stays (3.4%).

There was considerable variation in hospital performance based on the risk-adjusted 30-day home time.

In hospitals where the risk-adjusted 30-day home time increased, there was a gradual decline:

  • hospital mortality: Q1: 1.40% vs Q4: 0.76%

  • Mortality at 30 days: Q1: 2.31% vs Q4: 1.37%

  • Readmissions at 30 days: Q1: 14.36% vs Q4: 10.8%

  • Composed of 30 days of hospitalization and 30 days stroke, major bleeding and acute kidney injury requiring dialysis: Q1: 4.94% vs Q4: 3.56% (P for all

A significant inverse correlation was observed between risk-adjusted 30-day home time in hospital and risk-adjusted 30-day readmission (r = -0.465; P P

In contrast, no such correlation was found between the proposed metric and the hospital’s annual TAVR volume or between TAVR volume and readmission or 30-day risk-adjusted mortality.

Long-term outcomes followed a similar trend, with 1-year mortality of 11.58% in the worst-performing hospitals compared to 9.47% in the best-performing hospitals and 1-year readmission rates of 45, 78% versus 41.31%, respectively (both P

The proposed time-at-home measure improved the classification of 20.1% of hospitals by at least two quartiles and downgraded 19.3% of hospitals by at least two quartiles to a lower performing stratum, compared to the annual volume of TAVI for hospitals (net reclassification index: 0.394; P

Hospitals that were upgraded had significantly lower 30-day and 1-year mortality than those that were upgraded. Similar reclassification results were seen when the new measure was compared to 30-day risk-adjusted readmissions and mortality.

Pandey noted that there has been considerable evolution in TAVR technology over the past two years, but also a plateau in technical expertise or preclinical nuances that make it difficult to distinguish hospital performance based on volume alone. Overall results have also improved.

“It is a complementary measure to existing measures of volume, mortality and readmission, as it is probably the most patient-centric measure, but also the one with the widest distribution”, a- he declared. “So there’s better granularity to distinguish high performance from low, even on the right side of the spectrum where performance is typically higher.”

Matthew Sherwood MD, MHS, Inova Heart and Vascular Institute, Falls Church, Virginia, agreed that the 30-day home time is in addition to measures currently in use and said it may better align with how patients enjoy their TAVR care.

“Honestly, patients want to be alive, well, and home as soon as possible after a procedure, especially a less invasive procedure like TAVR, and this metric provides that and is very easy to interpret from both the side health care providers and on the patient side,” he said. | Medscape Cardiology.

An outcome measure that tracks time spent at home may also better align patient and provider incentives, Sherwood suggests in a accompanying editorial, co-authored with Amit Vora, MD, MPH, University of Pennsylvania Medical Center Heart and Vascular Institute. In the absence of a bundled payment scheme for TAVI with a financial penalty for unplanned readmission to hospital within 30 days, healthcare professionals are incentivized to minimize length of stay and discharge patients home. Early discharge to another care facility may also trigger the post-acute care transfer penalty.

The study, however, relied on administrative claims for comorbidities and diagnoses, Sherwood notes, and the multivariate model data used for validation lacked granular clinical features. Additionally, only Medicare beneficiaries were included, highlighting the need to measure time spent at home for 30 days in larger and more diverse populations.

That said, it’s an important first step. “I think this could honestly go forward and be used as a really nice metric for patients and providers to help providers and patients understand what quality is after TAVR,” Sherwood said in an interview.

Pandey said other next steps include seeing how time spent at home over 30 days correlates with other patient-reported measures of quality of life and understanding differences in low time spent at home factors. house in different hospitals and among all racial groups.

“It’s important to understand that if you don’t have access to care, your time at home can be artificially increased” and “if you can’t afford to be in an SNF, you end up staying at home , even though you may be suffering,” he said. “So I think we need to be aware of the limitations of this metric and make sure it doesn’t exacerbate disparity.”

Pandey has served on the advisory board of Roche Diagnostics; received in-kind support from Pfizer and Merck; and has received research support from the Texas Health Resources Clinical Scholarship, Gilead Sciences Research Scholar Program, National Institute on Aging GEMSSTAR Grant, and Applied Therapeutics. Co-author disclosures are listed in the original article. Sherwood has received honoraria/consulting fees from Medtronic and Boston Scientific. Vora received consulting fees from Medtronic.

J Am Coll Cardiol. Published online January 10, 2022. Summary, Editorial

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