Practice Pattern Variation in the Use of Transesophageal Echocardiography for Open Valve Cardiac Surgery

Abstract

Objective: The authors sought to assess for the presence of practice variation in the use of intraoperative transesophageal echocardiography (TEE) for open cardiac valve surgery.

Design: This study was a retrospective cohort analysis.

Setting: The administrative claims data used for this investigation were multi-institutional and a representative sample of commercially insured patients in the United States between 2010 and 2015.

Participants: The cohort consisted of adult patients, aged 18 years or older, undergoing open mitral valve (MV) or aortic valve (AV) surgery.

Interventions: This was an observational analysis without interventions.

Measurements and main results: Of 19,386 valve surgeries, 12,313 (64%) underwent AV replacement, 6,192 (32%) underwent MV repair or replacement, and 881 (<5%) underwent both MV and AV surgery. The overall rate of intraoperative TEE was 82% (95% confidence interval [CI]: 81%-82%), less frequently observed in AV procedures compared to MV or combined MV-AV procedures (80% v 85%, p < 0.001). Rates of intraoperative TEE claims varied markedly across U.S. states. After adjustment, the relative odds of an intraoperative TEE claim ranged across states from 0.26 (Louisiana, 95% CI: 0.18-0.36; p < 0.001) to 2.10 (North Carolina, 95% CI: 1.57-2.82; p < 0.001).

Conclusion: Among adult patients undergoing open AV or MV surgery in the United States, 82% had a claim for an intraoperative TEE with marked variability across U.S. states. Increasing adherence to intraoperative TEE guidelines for valve surgery may represent an unrecognized opportunity to improve the quality of cardiac surgical care.

Keywords: aortic valve surgery; cardiovascular surgery; ethics and policy; guideline compliance and adherence; health services; intraoperative echocardiography; mitral valve surgery; transesophageal echocardiography.

Figure 1:

Geographic variation in TEE guideline adherence among 19,386 undergoing aortic valve or mitral valve surgery from 2010 – 2015. The overall rate of TEE utilization observed in the data set was 82% (95% CI 81 – 82%). Among states with a minimum of 100 eligible cases, TEE utilization varied from 61% in both AL (95% CI: 56 – 66%) and LA (95% CI: 53 – 68%) to 92% (NC, 95% CI: 90 – 94%).

Figure 2:

Geographic variation in TEE guideline adherence among 12,313 undergoing aortic valve replacement surgery from 2010–2015. The overall rate of TEE utilization observed in the aortic valve subgroup was 80% (95% CI 79 – 81%). Among states with a minimum of 100 cases, TEE utilization varied from 49% (AL; 95% CI 41 – 56%) to 92% (NC; 95% CI: 89 – 94%).

Figure 3:

Geographic variation in TEE guideline adherence among 7,073 undergoing mitral valve repair or replacement surgery from 2010 – 2015. The overall rate of TEE utilization observed in the mitral valve subgroup was 85% (95% CI 84 – 86%). Among states with a minimum of 100 cases, TEE utilization varied from 73% (TN; 95% CI: 65 – 80%) to 94% (UT; 95% CI: 88 – 97%).