Effect of Transcatheter Aortic Valve Replacement Program Ratings on Case Selection.

BACKGROUND

Public reporting of transcatheter aortic valve replacement (TAVR) outcomes by U.S. News & World Report (USNWR) began in August 2020. The impact of these ratings on case selection has not been studied.

OBJECTIVES

The aim of this study was to evaluate the impact of USNWR hospital TAVR ratings on patient risk profile.

METHODS

Medicare fee-for-service beneficiaries undergoing TAVR at rated hospitals before and after the release of the USNWR ratings were identified. The causal effect of hospital ratings on patient risk profile (Elixhauser comorbidity score) was estimated using a difference-in-difference analysis comparing lower rated hospitals (average or below average) to high-performing hospitals.

RESULTS

There were 138,147 TAVR patients in the prerating period and 50,650 patients in the postrating period treated at 618 hospitals. Prior to ratings release, all hospitals had similar yearly trends in TAVR patient risk profile. After ratings release, patients treated at lower rated hospitals exhibited a significantly greater decline in Elixhauser comorbidity score compared with those treated at higher rated hospitals (difference-in-difference estimator = -0.48; 95% CI: -0.66 to -0.31; P < 0.0001). Similarly, although all hospitals exhibited declines in the number of high-risk TAVR cases (Elixhauser comorbidity score > 20), lower rated hospitals exhibited a significantly greater decline (incidence rate ratio: 0.56; 95% CI: 0.51-0.62; P < 0.0001).

CONCLUSIONS

Since 2020, there has been a substantial decline in the number of high-risk patients receiving TAVR across the United States, driven predominantly by hospitals that received lower USNWR TAVR ratings. This is likely, in part, driven by risk aversion, however, further research is required to understand the reasons behind this decline and identify mitigation strategies.