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Observational Study
. 2021 Aug 17;10(16):e020490.
doi: 10.1161/JAHA.120.020490. Epub 2021 Aug 13.

Association Between Patient Survival and Clinician Variability in Treatment Rates for Aortic Valve Stenosis

J Matthew Brennan  1 , Angela Lowenstern  1 , Paige Sheridan  2   3 , Isabel J Boero  3 , Vinod H Thourani  4 , Sreekanth Vemulapalli  1 , Tracy Y Wang  1 , Otto Liska  3 , Stuart Gander  3 , Jason Jager  3 , Martin B Leon  5 , Eric D Peterson  1
Affiliations
Observational Study

Association Between Patient Survival and Clinician Variability in Treatment Rates for Aortic Valve Stenosis

J Matthew Brennan et al. J Am Heart Assoc. .

Abstract

Background Patients with symptomatic severe aortic stenosis (ssAS) have a high mortality risk and compromised quality of life. Surgical/transcatheter aortic valve replacement (AVR) is a Class I recommendation, but it is unclear if this recommendation is uniformly applied. We determined the impact of managing cardiologists on the likelihood of ssAS treatment. Methods and Results Using natural language processing of Optum electronic health records, we identified 26 438 patients with newly diagnosed ssAS (2011-2016). Multilevel, multivariable Fine-Gray competing risk models clustered by cardiologists were used to determine the impact of cardiologists on the likelihood of 1-year AVR treatment. Within 1 year of diagnosis, 35.6% of patients with ssAS received an AVR; however, rates varied widely among managing cardiologists (0%, lowest quartile; 100%, highest quartile [median, 29.6%; 25th-75th percentiles, 13.3%-47.0%]). The odds of receiving AVR varied >2-fold depending on the cardiologist (median odds ratio for AVR, 2.25; 95% CI, 2.14-2.36). Compared with patients with ssAS of cardiologists with the highest treatment rates, those treated by cardiologists with the lowest AVR rates experienced significantly higher 1-year mortality (lowest quartile, adjusted hazard ratio, 1.22, 95% CI, 1.13-1.33). Conclusions Overall AVR rates for ssAS were low, highlighting a potential challenge for ssAS management in the United States. Cardiologist AVR use varied substantially; patients treated by cardiologists with lower AVR rates had higher mortality rates than those treated by cardiologists with higher AVR rates.

Keywords: aortic valve replacement; physician variability; symptomatic severe aortic stenosis.

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Conflict of interest statement

Dr Brennan reports consulting and speaking funds from Edwards Lifesciences and AtriCure. Dr Boero reports consulting for Edwards Lifesciences. Dr Thourani reports research and advising for Edwards Lifesciences. Dr Vemulapalli reports grants/contracts from the American College of Cardiology, Society of Thoracic Surgeons, Abbott Vascular, Boston Scientific, National Institutes of Health (R01 and Small Business Innovation Research grants), Food and Drug Administration National Evaluation System for health Technology Coordinating Center (FDA NESTcc), and Cytokinetics and advisory board/consulting/honoraria with Boston Scientific, American College of Physicians, Janssen, Edwards Lifesciences, and HeartFlow. Dr Wang reports research grants to the Duke Clinical Research Institute from Abbott, AstraZeneca, Bristol Myers Squibb, Boston Scientific, Cryolife, Chiesi, Merck, Portola, and Regeneron and consulting honoraria from AstraZeneca, Bristol Myers Squibb, Cryolife, and Novartis. Mr Liska, Mr Gander, and Mr Jager report consulting for Edwards Lifesciences. Dr Peterson reports being a coinvestigator on the American College of Cardiology Society of Thoracic Surgeons Transcatheter Valve Therapy TAVR Registry. The remaining authors have no disclosures to report.

Figures

Figure 1
Figure 1. Modified consort diagram.
The 26 438 patients were managed by 1627 cardiologists. EHR indicates electronic health record; IDN, integrated delivery network; LVAD, left ventricular assist device; and ssAS, symptomatic severe aortic stenosis.
Figure 2
Figure 2. Treatment rates stratified by TAVR/SAVR over time.
Overall, 35.6% patients with symptomatic severe aortic stenosis (ssAS) had aortic valve replacement (n=9407) in the year after date of first ssAS diagnosis, whereas 37.3% of patients who had aortic valve replacement underwent TAVR (n=3513). SAVR indicates surgical aortic valve replacement; and TAVR, transcatheter aortic valve replacement.
Figure 3
Figure 3. Survival stratified by managing cardiologist treatment rate.
Kaplan–Meier curves for survival when stratified by managing cardiologist AVR treatment rate with 1 representing the lowest quartile of AVR rates at the 1‐year AVR rate and 4 the highest. Patients treated by cardiologists with higher AVR rates have a significantly higher survival at 1 year. The colored bands around each survival cure represent the 95% CI. The number of patients at risk at each 60‐day interval for each quartile are displayed below the survival curves. AVR indicates aortic valve replacement.
Figure 4
Figure 4. Association between the managing cardiologists' AVR treatment rate and 1‐year all‐cause mortality.
Association between managing cardiologists' 1‐year AVR treatment rate and 1‐year all‐cause mortality was modeled as a restricted cubic spline with 4 degrees of freedom. The hazard presented was adjusted for patient factors and demographics and demonstrates that a higher clinician 1‐year treatment rate is associated with a significantly reduced 1‐year mortality risk. The distribution of clinicians by 1‐year AVR rate is shown below the curve with each strike representing an individual clinician. The light blue band around the line represents the 95% CI. AVR indicates aortic valve replacement.
See this image and copyright information in PMC

References

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