Abstract 360: How Should We Measure Quality of Care for Transcatheter Aortic Valve Implantation (TAVI)? Results for 6 Quebec TAVI Programs Compared with International Registries

Abstract

Background: Our publicly funded cardiology evaluation unit examined quality indicators relating to the use and outcomes of transcatheter aortic valve implantation (TAVI). We compared results in Québec hospitals with registries around the world. Methods: We abstracted data on all TAVI cases (n=294) in 6 hospitals in 2013-14. Variables, outcomes and definitions were chosen to facilitate comparisons with registries. Results were presented to TAVI teams with the goal of choosing quality indicators and improving performance. Results: Annual TAVI center volume ranged from 30 to 115 and rate of TAVI varied widely across Quebec’s 16 health regions, as did rates around the world. Median patient age was 83 years (interquartile range [IQR]: 78-86) with little variation across centers and international registries. Documented proportion of patients with NYHA class III/IV was 64% (188/294) for Quebec and varied from 75 to 86% across registries. A surgical risk score (STS) was recorded in only 53% (156/294) of Quebec patients but was often obligatory in registries. The median STS score for Quebec was very similar to that reported in the USA [6% (IQR: 4-10) vs 7% (IQR: 5-11), respectively] but was much lower than in France, Austria and Brazil. Frequency of in-hospital adverse events varied widely across Québec centers: stroke (0-7.5%), bleeding (16.7-26.7%) and transfusion (16.7-43.3%). Overall incidence of in-hospital stroke was 2.3% (7/294) and varied from 1.8 to 5.3% across registries. Bleeding and transfusion were rarely reported in registries. Conversion to surgery was 3% (9/294) in Quebec, and 0.4-4.3% in registries. In Quebec, 15% of patients required a new pacemaker, with wide variation across centers (0-21%) and registries (6.6-25%). Rates of procedural success varied widely across Quebec, largely due to non-standardized classification of post-TAVI aortic regurgitation. Such classification also varied across registries. Overall procedural success for Quebec (73%; 215/294) was lower than in registries but in the latter, the definition of success was often unclear. In-hospital mortality in Quebec was 6.5% (19/294) versus 5.5% in USA and a reported 5.1% for transvascular and 7.7% for transapical TAVI in Germany. Other registries only reported 30-day mortality, varying from 4.1 to 9.1%. Discharge home was more likely in Quebec (80%) than the USA (63%); this outcome was not reported elsewhere. Conclusions: Practice and outcomes in TAVI vary widely across Quebec hospitals and internationally. Despite publication of recommended endpoints (VARC and BARC), there is a lack of standardized reported outcomes and patient populations. While quality benchmarks for patient selection and outcomes remain unclear, continued monitoring with timely feedback to TAVI teams and decision-makers is essential for this new and costly intervention that is predominantly being performed in the very elderly.