Fragmented TAVR Care Common, Linked to Death and Readmission

Nearly 60% of patients discharged after undergoing TAVR will be readmitted to a different hospital in the first 90 days, according to data from the STS/ACC TVT Registry. At 1 year, this type of fragmented care was associated with a greater likelihood of death and all-cause readmission compared with continuous care at the same center where the TAVR was performed.

“If it turned out that care fragmentation didn't matter in a measurable way, I think the conversation might be a little different,” said senior study author Sreekanth Vemulapalli, MD (Duke University Medical Center, Durham, NC), in an interview with TCTMD. “But there seems to be a potential downside to care fragmentation, at least in long-term results, and that's the key point here.”

Vemulapalli said the potential negative health impact of patients not returning to their TAVR center needs to be part of ongoing, but highly complicated conversations about care pathways for this population.

If it turned out that care fragmentation didn't matter in a measurable way, I think the conversation might be a little different. Sreekanth Vemulapalli

“Exactly how to implement a policy to lower the amount of fragmentation is quite complex. What may be less difficult to determine is how [to] communicate better,” he said. “How can we incentivize the system to provide good continuity of care? That’s something that policy makers should think about instead of only looking at geographic access to care, which can never be perfect for anyone.”

Fragmented Care as an Independent Predictor of Mortality

For the study, published online June 27, 2019, in the American Journal of Cardiology, Vemulapalli and colleagues led by Alice Wang, MD (Duke University Medical Center), examined registry data on 8,927 patients who underwent TAVR between 2011 to 2015 at 374 US sites. In all, 57% of patients had fragmented care, defined as at least one readmission to a center different than where their TAVR was performed within 90 days of discharge. Of the 13,052 total readmissions, 52% were for cardiovascular causes.

Compared with continuous care, fragmented care was more likely to be associated with emergent/traumatic readmissions. Patients also had a higher risk of fragmented care if they had comorbidities such as chronic lung disease, cerebrovascular disease, and heart failure.

For the primary endpoint of 1-year mortality, the incidence of death was 24.3% in the fragmented care group and 19.3% in the continuous care group (P < 0.001). Fragmented care patients also had significantly higher rates of bleeding and all-cause remission at 1 year. In adjusted analyses, fragmented care remained a predictor of increased mortality and all-cause readmission at 1 year. Fragmented care was not associated with greater risks of TAVR-related complications such as stroke, bleeding, or heart failure. Wang and colleagues suggest that the increased rates of death and readmission, therefore, may be most relevant to high-risk populations “that may benefit from continuous care to manage their multiple comorbidities.”

When the researchers looked at how far patients had to travel to reach the center that performed their TAVR they found that those who received fragmented care lived farther away than those whose care was continuous (42.9 vs 15.5 miles) and had more than double the driving time (52 vs 24 min; P < 0.001 for both). Within the first half hour, the likelihood of experiencing fragmented care was nearly 2.5 times higher for every 10 minutes of extra driving. After the first 30 minutes of driving, the magnitude of the effect of extra driving time decreased, however.

The researchers also looked at geographic demographics and found both an unequal distribution of care fragmentation and an unequal distribution of TAVR volume relative to Medicare patients at the state level. States located in the Northeast and Midwest had the highest TAVR volumes in general and the lowest corresponding rates of fragmentation, but states like Alabama and New Mexico, where TAVR volumes were among the lowest in the nation, had the highest rates of fragmentation.

To TCTMD, Vemulapalli said the disparities seem to be reflective of issues with both distance and access to TAVR-capable centers, noting that the findings have relevance to the wide-ranging debate regarding Centers for Medicare & Medicaid Services (CMS) requirements for TAVR centers, for which a final “decision memo” finalizing plans for the national coverage determination for reimbursement was recently released. In order to be reimbursed, CMS will require hospitals with existing TAVR programs to maintain certain procedure volumes.

“When you put in a volume requirement, you are necessarily excluding some places, and when you do that you might be causing problems with access,” Vemulapalli noted. “This kind of discussion about how we deliver care as a nation, as typified by fragmentation, is important as TAVR as a field matures.”