Transcatheter Aortic Valve Replacement (TAVR) in Medicare Advantage and Medicare Fee-for-Service: Differences in Patient Characteristics, Utilization, and Outcomes.

BACKGROUND

Over half of Medicare beneficiaries are enrolled in privately administered Medicare Advantage (MA) plans, and aortic stenosis predominantly affects older patients. In this study, we evaluated whether differences in care delivery between MA and fee-for-service (FFS) Medicare contribute to cardiovascular outcomes after transcatheter aortic valve replacement (TAVR).

METHODS

Medicare patients who underwent TAVR from January 1, 2018, to December 31, 2022, were eligible for cohort inclusion. TAVR utilization rates in MA and FFS were calculated as the age- and sex-standardized number of procedures per 10 000 person-years. Patient characteristics were compared between MA and FFS using standardized mean differences (SMDs), with an SMD ≥10 considered meaningful. The association of MA versus FFS enrollment with 30-day and 1-year outcomes was assessed using logistic and Cox regression models, respectively.

RESULTS

Among the 317 630 patients (64.4% FFS, 35.6% MA) undergoing TAVR, the mean age was 80.6±7.0 years, and 55.1% were male. TAVR utilization rates were similar between MA and FFS, with 11.2 TAVRs/10 000 person-years in FFS compared with 11.7 TAVRs/10 000 person-years in MA by the end of the study. Compared with FFS patients, MA patients were more likely to be Black (5.4% versus 3.0%; SMD, -11.9) and dual-enrolled in Medicaid (13.7% versus 8.6%; SMD, -16.3). Comorbidity profiles were similar (SMD, <10). In the comorbidity-adjusted model, MA patients had lower odds of 30-day death (adjusted odds ratio, 0.90 [95% CI, 0.86-0.95]). At 1 year, MA patients had a lower adjusted risk of death (hazard ratio, 0.94 [95% CI, 0.92-0.96]), all-cause readmission (hazard ratio, 0.86 [95% CI, 0.85-0.88]), stroke (hazard ratio, 0.90 [95% CI, 0.87-0.94]), and aortic valve reintervention (hazard ratio, 0.86 [95% CI, 0.76-0.96]).

CONCLUSIONS

Despite similar clinical profiles and TAVR utilization, MA patients appeared to experience better 30-day and 1-year outcomes than FFS patients. Differences in care delivery may contribute, but future studies are needed to understand differences in outcomes.