Medicare data reveal ‘highly concerning’ TAVR trends—are hospital rankings to blame?
The hospital rankings published by U.S. News & World Report may be making a significant impact on transcatheter aortic valve replacement (TAVR) trends in the United States, according to a new analysis published in JACC: Cardiovascular Interventions.[1]
“When outcomes were first publicly reported for coronary artery bypass graft surgery and percutaneous coronary intervention (PCI), multiple studies demonstrated risk-averse behavior among physicians and hospitals, particularly among those rated below their peers or peer institutions,” wrote first author Tayyab Shah, MD, a researcher with the Hospital of the University of Pennsylvania, Philadelphia, and colleagues. “The broad concern with risk-averse behavior is that high-risk but indicated procedures are being forgone, to the detriment of patients. Indeed, risk-averse behavior could be particularly harmful in the domain of TAVR, because severe aortic stenosis patients who are not surgical candidates have one-year mortality rates as high as 50% without TAVR. However, to date, the effect of TAVR hospital ratings on subsequent case selection has not been systematically studied.”
Shah et al. tracked Medicare data from before and after U.S. News & World Report started publishing TAVR rankings in 2020. This included data from nearly 140,000 TAVR patients treated before the first rankings were published and more than 50,000 TAVR patients treated after those first rankings. All patients were seen at one of 618 U.S. hospitals.
Overall, the group found that the number of high-risk TAVR cases being performed decreased substantially after the rankings were published. This decline was approximately 44% greater at hospitals that received lower TAVR rankings from U.S. News & World Report than those that received higher TAVR rankings.
The study’s authors shared their concerns about these findings.
“It is highly unlikely that there has been a decline in the number of these patients presenting to medical care, particularly in a time period in which there were growing initiatives to improve identification of aortic stenosis and a substantial increase in the number of TAVR-capable hospitals,” the authors wrote. “Thus, this observed decline in the number of high-risk patients undergoing TAVR across multiple data sets is highly concerning and suggests that high-risk patients who would have undergone TAVR in 2019 or before are now more often being declined.”
One potential explanation for this trend is the COVID-19 pandemic. Another is the fact that cardiologists are learning more about TAVR—including which patients are the best fit and when to consider surgery instead—with each passing year. Even with these things in mind, however, the authors believe hospitals may be making decisions specifically with their TAVR rankings in mind.
“Another potential cause is risk-averse behavior in response to the U.S. News & World Report ratings in the hope of improving TAVR ratings,” the authors wrote. “For example, risk aversion by providers and hospitals has occurred in states when PCI outcomes became publicly reported, with up to 65% of interventionalists in certain states reporting avoiding PCI on at least two occasions because of perceived pressure from publicly reported outcomes.”
Shah and colleagues did emphasize that these findings do not specifically prove TAVR rankings are impacting TAVR trends in the United States. Additional research is still required, they concluded, to “better understand the reasons behind this decline and identify mitigation strategies.”
Veteran cardiologist shares his perspective
Frederick G.P. Welt, MD, a cardiologist with the University of Utah Health who specializes in TAVR, shared his thoughts on these findings in a separate commentary. Like the full analysis, his editorial was published in JACC: Cardiovascular Interventions.[2]
Welt noted that rankings based on healthcare data have their advantages as well as their disadvantages. Receiving a great score, for example, can be an effective marketing tool that helps hospitals stand out. The potential downside, however, is that the rankings may influence important treatment decisions in a negative way—and they may not even be totally accurate.
“This study offers valuable insight into national trends of TAVR therapy that may be influenced by public reporting and ranking,” Welt wrote, adding that “risk-averse behavior is well documented in response to public reporting of outcomes from other cardiac procedures.” Like the study’s authors, though, he was quick to note that there are certain limitations to consider.
Welt also noted that it remains unclear just how much data patients want about a hospital when they consider their own care. Most patients would likely want to know about such outcomes as morbidity and mortality, but what about other details like patient-to-staff ratios and the overall patient experience?
“At the end of the day, physicians and institutions can control only how they respond to public data,” he concluded. “An ideal ranking system would 1) accurately inform patients about the quality of an institution; 2) provide actionable information to the institution about how it might adapt its care processes to improve; and 3) have contingencies in place to protect the highest risk patients from inappropriate risk-averse practices. The absence of such an ideal system does not mean that U.S. News & World Report and other registries do not provide actionable data and the model of a learning health system can use these data to improve. As always, more research into the thorny issue of risk-averse behavior should continue, and the investigators should be commended for their contribution to the discussion.”
Click here to read the full analysis from Shah et al. The commentary by Welt is available here.
Michael has more than 19 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.