Clinical and economic outcomes after surgical aortic valve replacement in Medicare patients

Background: Aortic valve replacement (AVR) is the standard of care for patients with severe, symptomatic aortic stenosis who are suitable surgical candidates, benefiting both non-high-risk and high-risk patients. The purpose of this study was to report long-term medical resource use and costs for patients following AVR and validate our assumption that high-risk patients have worse outcomes and are more costly than non-high-risk patients in this population. Methods: Patients with aortic stenosis who underwent AVR were identified in the 2003 Medicare 5% Standard Analytic Files and tracked over 5 years to measure clinical outcomes, medical resource use, and costs. An approximation to the logistic EuroSCORE (European System for Cardiac Operative Risk Evaluation) based on administrative data was used to assess surgical risk, with a computed logistic EuroSCORE > 20% considered high-risk. Results: We identified 1474 patients with aortic stenosis who underwent AVR, of whom 1222 (82.9%) were non-high-risk and 252 (17.1%) were high-risk. Among those who were non-high-risk, the mean age was 73.3 years, 464 (38.2%) were women, and the mean logistic EuroSCORE was 7%, whereas in those who were high-risk, the mean age was 77.6 years, 134 (52.8%) were women, and the mean logistic EuroSCORE was 37%. All-cause mortality was 33.2% for non-high-risk and 66.7% for high-risk patients at 5 years. Over this time period, non-high-risk patients experienced an average of 3.9 inpatient hospitalizations and total costs of $106,277 per patient versus 4.7 hospitalizations and total costs of $144,183 for high-risk patients. Conclusion: Among elderly patients undergoing AVR, long-term mortality and costs are substantially greater for high-risk than for non-high-risk individuals. These findings indicate that further research is needed to understand whether newer approaches to aortic valve replacement such as transcatheter AVR may be a lower cost, clinically valuable alternative.

[1]  R. Bansal,et al.  Survival in elderly patients with severe aortic stenosis is dramatically improved by aortic valve replacement: Results from a cohort of 277 patients aged > or =80 years. , 2006, European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery.

[2]  T. Sundt,et al.  Quality of Life After Aortic Valve Replacement at the Age of >80 Years , 2000, Circulation.

[3]  O. Lund.  Preoperative risk evaluation and stratification of long-term survival after valve replacement for aortic stenosis. Reasons for earlier operative intervention. , 1990, Circulation.

[4]  S. Yun,et al.  Early Surgery Versus Conventional Treatment in Asymptomatic Very Severe Aortic Stenosis , 2010, Circulation.

[5]  O. Bouchot,et al.  Analysis of outcome after using high-risk criteria selection to surgery versus endovascular repair in the modern era of abdominal aortic aneurysm treatment. , 2010, European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery.

[6]  Stuart J Pocock,et al.  Transcatheter versus surgical aortic-valve replacement in high-risk patients. , 2011, The New England journal of medicine.

[7]  Lisa I. Iezzoni,et al.  Risk Adjustment of Medicare Capitation Payments Using the CMS-HCC Model , 2004, Health care financing review.

[8]  S. Pocock,et al.  Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. , 2010, The New England journal of medicine.

[9]  R. Bergström,et al.  Observed and relative survival after aortic valve replacement. , 2000, Journal of the American College of Cardiology.

[10]  Claire Duvernoy,et al.  Evaluation of Patients With Severe Symptomatic Aortic Stenosis Who Do Not Undergo Aortic Valve Replacement: The Potential Role of Subjectively Overestimated Operative Risk , 2009, Circulation. Cardiovascular quality and outcomes.

[11]  M. Hlatky,et al.  Cost-effectiveness of transcatheter aortic valve replacement. , 2012, Circulation.

[12]  J. Seward,et al.  Aortic valve replacement for aortic stenosis with severe left ventricular dysfunction. Prognostic indicators. , 1997, Circulation.

[13]  Franz Schwarz,et al.  The Effect of Aortic Valve Replacement on Survival , 1982, Circulation.

[14]  S. Rahimtoola,et al.  Severe Aortic Stenosis with Impaired Left Ventricular Function and Clinical Heart Failure: Results of Valve Replacement , 1978, Circulation.

[15]  S. Rahimtoola,et al.  Severe Aortic Stenosis in Patients 60 Years of Age and Older: Left Ventricular Function and 10‐year Survival After Valve Replacement , 1981, Circulation.

[16]  W. Baine,et al.  The Agency for Healthcare Research and Quality , 2006, Italian Journal of Public Health.

[17]  N. Kouchoukos,et al.  Replacement of the aortic root with a pulmonary autograft in children and young adults with aortic-valve disease. , 1994, The New England journal of medicine.

[18]  J. Tijssen,et al.  To operate or not on elderly patients with aortic stenosis: the decision and its consequences , 1999, Heart.

[19]  W. O’Neill,et al.  Cost-Effectiveness of Transcatheter Aortic Valve Replacement Compared With Standard Care Among Inoperable Patients With Severe Aortic Stenosis: Results From the Placement of Aortic Transcatheter Valves (PARTNER) Trial (Cohort B) , 2012, Circulation.

[20]  J. Ennker,et al.  Aortic valve replacement in octogenarians: identification of high-risk patients. , 2010, European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery.