Outcomes After Transcatheter Aortic Valve Replacement Among Medicare Beneficiaries: The Impact of Frailty and Social Vulnerability

Abstract

Background: Transcatheter aortic valve replacement (TAVR) is an accepted alternative to surgery in many patients with severe aortic stenosis. Clinical trials have evaluated early and late outcomes in selected TAVR patients, but predictors of late mortality have been less well studied in a broadly inclusive, national patient cohort undergoing TAVR. We sought to characterize 5-year outcomes after TAVR in Medicare beneficiaries and to evaluate the incremental predictive value of demographics, comorbidities, procedural factors, frailty, and social vulnerability in determining late mortality risk.

Methods: We studied the fee-for-service Centers for Medicare & Medicaid Services MedPAR database that includes patients aged ≥65 years undergoing TAVR between 2017 and 2022. The primary endpoint was 5-year mortality. Sequential multivariable Cox models were constructed, incrementally adjusting for demographics, comorbidities, procedural and hospital characteristics, and frailty and social vulnerability. Model performance was assessed using C-statistics and integrated discrimination improvement (IDI).

Results: A total of 371,248 TAVR patients were included in the analysis. The baseline model, including only demographic factors (age, sex, and race), yielded modest model performance (C = 0.589). Inclusion of comorbidities improved the model discrimination substantially (C = 0.684; IDI +6.9%, p < 0.001), and adding hospital and procedural characteristics yielded additional gains (C = 0.695; IDI +0.9%, p < 0.001). The final model integrated frailty and social vulnerability and achieved the highest predictive accuracy (C = 0.705; IDI +1.0%, p < 0.001).

Conclusions: In this large national cohort, frailty and social vulnerability significantly improved risk prediction for long-term mortality after TAVR. We conclude that sociodemographic and frailty-related factors are important components for prediction of 5-year mortality after TAVR.

Keywords: Frailty; Long-term mortality; Medicare; Social vulnerability; Transcatheter aortic valve replacement (TAVR).

Figure 1

Multivariable predictors of in-hospital (a) and 5-year (b) mortality. Factors listed in black are significant predictors, whereas factors listed in red are not significant predictors. Reference for SVI is Q1 (least vulnerable), for frailty is low-risk, and for admission type is elective TAVR. Abbreviations: SVI, Social Vulnerability Index; TAVR, transcatheter aortic valve replacement.

Figure 2

Impact of frailty and SVI on in-hospital and 5-year all-cause mortality. The forest plot shows the impact of the SVI and Frailty classification on in-hospital and 5-year mortality. Quartile 1 was the lowest risk for social vulnerability, and quartile 4 was the highest risk for social vulnerability. Intermediate and high frailty risk were compared to low risk for frailty. The upper panel indicates SVI and the bottom panel illustrates Frailty. Abbreviation: SVI, Social Vulnerability Index.

Figure 3

Five-year survival by TAVR vs. age-sex-race-matched US life expectancy. Unadjusted mortality rates in blue (TAVR). The orange line indicates the age-sex-race-matched US survival curves from life tables. Source for life tables: https://www.cdc.gov/nchs/data/nvsr/nvsr72/nvsr72-12.pdf. Abbreviation: TAVR, transcatheter aortic valve replacement.