These authors [1Murarka S. Lazkani M. Neihaus M. et al.Comparison of 30-day outcomes of transfemoral versus transapical approach for transcatheter aortic valve replacement: a single-center US experience.Ann Thorac Surg. 2015; 99: 1539-1545Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar] report their single-center experience with both transfemoral (TF) and transapical (TA) approaches for transcatheter aortic valve replacement (TAVR) in a United States population. Through a retrospective study design and selective matching of patient characteristics, two selected subpopulations are compared. The authors hypothesize that 30-day survival is at parity and that procedural efficiency (with metrics of procedure time, contrast volume, and fluoroscopy exposure) is enhanced with the TA approach. The authors are to be congratulated for (1) reinforcing that the current practice of using a TA approach when barriers to TF TAVR are present is, in fact, safe; for (2) reinforcing the observation that permanent pacemaker implantation is associated with a significant hazard of death (hazard ratio 7.1); and for (3) reinforcing the utility of efficiency in our literature. This third construct, the use of efficiency as an outcome, is intriguing. Efficiency is casually referenced daily. In an academic context, efficiency evolves into a more elusive but important paradigm. In a concerted effort to improve health care efficiency reporting, the Agency for Healthcare Research and Quality (AHRQ) enlisted a multidisciplinary team at RAND to categorize and evaluate health care efficiency measures (AHRQ publication No. 08-0030, April 2008). The systematic underperformance in efficiency assessment may be explained in part by the varying definitions of efficiency provided by vested entities. The Institute of Medicine in 2001 defined it as avoiding waste of equipment supplies, ideas, and energy. Economic theory has three definitions (technical, productive, and social). The Ambulatory Care Quality Alliance, the Government Accountability Office, and the Medicare Payment Advisory Commission each embrace institutionally centric definitions of efficiency. A notable takeaway from this white paper is the importance of “perspective” from which the efficiency is measured. Does the efficiency benefit society, the health care system, the provider, the procedure, the hospital, or the patient? Thus, the perspective from which efficiency is measured requires explicit acknowledgment. In the current report, the efficiency of aortic stenosis treatment was evaluated from the patient’s perspective. The authors propose that efficiency was improved with the TA procedure because the outcome was equal and the resource utilization (fluoroscopy time, contrast volume, and procedure time) were diminished: thus, increased efficiency. This may be a valid statement from the patient’s perspective for the procedure itself. Unfortunately, these are likely marginal costs, and they fail to represent meaningful utility. The argument for efficiency with TA becomes increasingly fragile when we consider that the length of stay (which trends toward a TF benefit) as an extra day in the hospital may supersede the benefits of procedure time, contrast volume, and fluoroscopy time from a broader health care perspective. Importantly, the realized cost data were not reported, so this weakens the generalizability of the authors’ claim of efficiency with respect to the TA approach for aortic stenosis. The authors are to be applauded for taking a bold step into the concept of efficiency. In the future, our readership and our regulatory bodies will expect this enhanced analytic structure when they evaluate therapeutic strategies. A universal approach to reporting health care efficiency will improve the influence of this research. Comparison of 30-Day Outcomes of Transfemoral Versus Transapical Approach for Transcatheter Aortic Valve Replacement: A Single-Center US ExperienceThe Annals of Thoracic SurgeryVol. 99Issue 5PreviewThe optimal access route for transcatheter aortic valve replacement (TAVR) remains debatable. We compared early safety outcomes at 30 days between the transfemoral (TF) and transapical (TA) approaches in a single, high-volume center in the United States. Full-Text PDF