Use of 90-Day Mortality More Appropriate For TAVR/SAVR Performance Evaluation


A study of TAVR and SAVR admissions over a 4-year period revealed 30-day mortality rates may be misrepresenting outcomes at 1 year.

Sameer Hirji, MD

Sameer Hirji, MD

A new analysis from the Division of Cardiac Surgery at Brigham and Women’s Hospital (BWH) is suggesting 30-day mortality rates may be misrepresenting hospital performance for transcatheter (TAVR) and surgical aortic valve replacements (SAVR).

Led by Sameer Hirji, MD, clinical fellow in surgery at BWH, results of the study indicate 90-day mortality rates may be a more appropriate and reliable outcome metric for evaluating hospital performance and procedure-related mortality at 1-year following both TAVR and SAVR procedures.

Using a nationally representative sample of Medicare beneficiaries who underwent TAVR or SAVR at hospitals between 2012 and 2015, investigators conducted a multicenter, cohort comparison of 30-day and 90-day mortality rates as quality metrics. A total of 30,329 TAVR admission from 184 hospitals and 26,021 SAVR admissions from 191 hospitals were included in the analysis.

The primary outcomes of interest in the study were 30-day, 90-day, and 1-year mortality. For the purpose of comparison, hospitals were ranked into 3 groups based upon there mean 30-day mortality rate during the 4-year study period—the groups were defined as top-performing (lowest 10%), middle-performing (middle 80%), and bottom-performing (highest 10%).

Of the 184 TAVR hospitals, 27 were included in the top-performing group, 130, 130 in the middle-performing group, and 27 in the bottom-performing group. Changes in performance ranking occurred in with 21.7% (n=40) of hospitals at 90 days and 30.4% (n=56) at 1 year.

In regard to changes when using 90-day mortality, 48.1% (n=13) in the top-performing group saw declines in their rankings while 29.6% (n=8) of the bottom-performing group improved their ranking. When examining mortality at 1 year, 77.8% (n=21) of hospitals in the top-performing group and 44.4% (n=12) in the bottom-performing group experienced changes in ranking. 

When examining SAVR, the 90-day conversion rate was 17.3% and that figure increased to 30.3% at 1 year. Investigators noted the results were consistent for TAVR and SAVR after adjustment for risk profiles.

Based on the results of their analyses, investigators suggested resulted indicated use of 30-day mortality rates could misrepresent performance after TAVR and SAVR surgeries. Subsequently, 90-day mortality rates proved to be a more reliable metric for measuring hospital performance.

Investigators pointed out a number of limitations in their study, including the study period ending in 2015 and is, therefore, unable to reflect current clinical practices and outcomes. Use of the CMS database also limited the study as investigators were unable to evaluate patient presentation, procedural and echocardiographic details, and STS risk scores.

This study, titled “Utility of 90-Day Mortality vs 30-Day Mortality as a Quality Metric for Transcatheter and Surgical Aortic Valve Replacement Outcomes,” is published in JAMA Cardiology.

Editor’s Note: Earlier this year, Hirji and study co-investigator Tsuyoshi Kaneko, MD, a cardiac surgeon at BWH and an assistant professor of surgery at Harvard Medical School, took part in an episode of the DocTalk Podcast where they discussed the current state of TAVR and SAVR. For more on that conversation, check out the audio below.

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