J. Hadaya1, Y. Sanaiha1, N. Cho1, B. Danielsen2, J. S. Carey3, R. J. Shemin1, P. Benharash1 1David Geffen School Of Medicine, University Of California At Los Angeles, Los Angeles, CA, USA 2Health Information Solutions, Rocklin, CA, USA 3University Of California – Irvine, Orange, CA, USA
Introduction: Following its introduction to the US market in 2011, transcatheter aortic valve replacement (TAVR) has been widely adopted for the management of symptomatic aortic stenosis. Requirements for establishment of heart teams, structural heart expertise, availability of appropriate operating suites, as well as financial considerations have been cited as potential barriers to adoption of TAVR. The purpose of the present study was to evaluate for the presence of regional disparities in access to and outcomes following TAVR in California.
Methods: The Office of Statewide Health Planning and Development database was queried for patients undergoing TAVR or isolated surgical aortic valve replacement (SAVR) from 2008 to 2018. The state of California was divided into 7 regions: Northern California, San Francisco Bay Area, Central California, Los Angeles, Inland Empire, Orange, and San Diego. Regional TAVR volumes were normalized to the number of regional Medicare beneficiaries or isolated SAVR volume. Institutional level data was examined for trends in volume and outcomes. Outcomes included risk-adjusted 30-day mortality and major adverse cardiovascular and cerebral events (MACCE), a composite of death, postoperative myocardial infarction, stroke, and re-intervention, following TAVR.
Results: Annual TAVR volume steadily increased since 2011, with 5,443 cases performed across California in 2018. The majority of TAVR programs (43, 72%) were established by 2016. Although isolated SAVR caseload decreased, total volume of aortic valve replacements increased to 7,766 in 2018 (Figure 1). After normalization, wide variation in utilization of TAVR was evident across California. At most, a 5.3-fold difference was present between the San Francisco Bay Area and Central California. TAVR to SAVR ratios in 2018 were greatest in Los Angeles (2.9) and San Diego (2.9), and least in Central California (1.7) and the Inland Empire (1.6). After risk adjustment, there were no significant regional differences in 30-day mortality, but lower 30-day MACCE in the San Francisco Bay Area.
Conclusion: Regional differences in TAVR utilization exist, with limited access in Central California and the Inland Empire, but risk-adjusted outcomes are similar. Efforts to reach underserved areas through expansion of existing programs or regional referral programs may distribute transcatheter technology more equitably across California. Furthermore, as other surgical and interventional techniques are developed, efforts to reduce disparities in access to care as these technologies are integrated into practice are imperative.
