Article Text
Abstract
Background There has been rapid growth in the demand for transcatheter aortic valve replacement (TAVR), which has the potential to overwhelm current capacity. This imbalance between demand and capacity may lead to prolonged wait times, and subsequent adverse outcomes while patients are on the waitlist. We sought to understand the relationship between regional differences in capacity, TAVR wait times and morbidity/mortality on the waitlist.
Methods and results We modelled the effect of TAVR capacity, defined as the number of TAVR procedures per million residents/region, on the hazard of having a TAVR in Ontario from April 2012 to March 2017. Our primary outcome was the time from referral to a TAVR procedure or other off-list reasons on the waitlist/end of the observation period as measured in days. Clinical outcomes of interest were all-cause mortality, all-cause hospitalisations or heart failure-related hospitalisations while on the waitlist for TAVR. There was an almost fourfold difference in TAVR capacity across the 14 regions in Ontario, ranging from 31.5 to 119.5 TAVR procedures per million residents. The relationship between TAVR capacity and wait times was complex and non-linear. In general, increased capacity was associated with shorter wait times (p<0.001), reduced mortality (HR 0.94; p=0.08) and all-cause hospitalisations (p=0.009).
Conclusions The results of the present study have important policy implications, suggesting that there is a need to improve TAVR capacity, as well as develop wait-time strategies to triage patients, in order to decrease wait times and mitigate the hazard of adverse patient outcomes while on the waitlist.
- aortic valve disease
- public health
- minimally invasive
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Footnotes
Contributors HCW is responsible for overall content as guarantor. KH, MR and HCW were involved in study conception. FQ performed all analyses. All authors were involved in interpretation of results. KH and MR drafted the manuscript. HCW, FQ, NM, TS and PA revised manuscript critically. The corresponding author affirms that he has listed everyone who contributed significantly to the work. The authors had access to all the study data, take responsibility for the accuracy of the analysis and had authority over manuscript preparation and the decision to submit the manuscript for publication. The corresponding author confirms that all authors read and approve the manuscript.
Funding This study was funded by a grant in aid from the Heart and Stroke Foundation of Canada. This study was supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care. HCW is supported by a Phase 2 Clinician Scientist Award from the Heart and Stroke Foundation of Canada, Ontario office. PA is supported by a Mid-Career Investigator award from the Heart and Stroke Foundation.
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Competing interests NF is a consultant for Edwards Life Sciences.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement No data are available. As per privacy laws in Ontario Canada, the data analysed for this manuscript are not publicly available.