PT  - JOURNAL ARTICLE
AU  - Rafael N Miranda
AU  - Feng Qiu
AU  - Ragavie Manoragavan
AU  - Stephen Fremes
AU  - Sandra Lauck
AU  - Louise Sun
AU  - Christopher Tarola
AU  - Derrick Y Tam
AU  - Mamas Mamas
AU  - Harindra C Wijeysundera
TI  - Drivers and outcomes of variation in surgical versus transcatheter aortic valve replacement in Ontario, Canada: a population-based study
AID  - 10.1136/openhrt-2021-001881
DP  - 2022 Jan 01
TA  - Open Heart
PG  - e001881
VI  - 9
IP  - 1
4099  - http://openheart.bmj.com/content/9/1/e001881.short
4100  - http://openheart.bmj.com/content/9/1/e001881.full
SO  - Open Heart2022 Jan 01; 9
AB  - Objectives To understand the patient and hospital level drivers of the variation in surgical versus trascatheter aortic valve replacement (SAVR vs TAVR) for patients with aortic stenosis (AS) and to explore whether this variation translates into differences in clinical outcomes.Background Adoption of TAVR has grown exponentially worldwide. Notwithstanding, a wide variation in TAVR rates has been seen within and between countries and in some jurisdictions AS is still primarily being managed by SAVR.Methods We conducted a population-based retrospective cohort study in Ontario, Canada, including individuals who received TAVR or SAVR between 2016 and 2020. We developed iterative hierarchical logistic regression models for the likelihood of receiving TAVR instead of SAVR examining sequentially patient characteristics, hospital factors and year of procedure, calculating the median ORs and variance partition coefficients for each. Using Cox proportional hazards models, we examined the relationship between TAVR/SAVR ratio on all-cause mortality and readmissions.Results Annual procedures rates per million population increased from 171 to 201, mainly driven by the expansion of TAVR. TAVR/SAVR ratios differed substantially between hospitals, from 0.21 to 3.27. Neither patient nor hospital factors explained the between-hospital variation in AS treatment. The TAVR/SAVR ratio was significantly associated with clinical outcomes with high ratio hospitals having lower mortality and rehospitalisations.Conclusions Despite the expansion of TAVR, dramatic variation exists that is not explained by patient or hospital factors. This variation was associated with differences in clinical outcomes, suggesting that further work is needed in understanding and addressing inequity of access.Data sets are not publicly available as per privacy legislation in Ontario, Canada.