Association of Volume and Outcomes in 234 556 Patients Undergoing Surgical Aortic Valve Replacement

Vinod H Thourani; James M Brennan; J James Edelman; Dylan Thibault; Oliver K Jawitz; Joseph E Bavaria; Robert S D Higgins; Joseph F Sabik; Richard L Prager; Joseph A Dearani; Thomas E MacGillivray; Vinay Badhwar; Lars G Svensson; Michael J Reardon; David M Shahian; Jeffrey P Jacobs; Gorav Ailawadi; Wilson Y Szeto; Nimesh Desai; Eric E Roselli; Y Joseph Woo; Sreek Vemulapalli; John D Carroll; Pradeep Yadav; S Chris Malaisrie; Mark Russo; Tom C Nguyen; Tsuyoshi Kaneko; Gilbert Tang; Marc Ruel; Joanna Chikwe; Richard Lee; Robert H Habib; Isaac George; Martin B Leon; Michael J Mack

doi:10.1016/j.athoracsur.2021.06.095

Association of Volume and Outcomes in 234 556 Patients Undergoing Surgical Aortic Valve Replacement

Vinod H Thourani, James M Brennan, J James Edelman, Dylan Thibault, Oliver K Jawitz, Joseph E Bavaria, Robert S D Higgins, Joseph F Sabik, Richard L Prager, Joseph A Dearani, Thomas E MacGillivray, Vinay Badhwar, Lars G Svensson, Michael J Reardon, David M Shahian, Jeffrey P Jacobs, Gorav Ailawadi, Wilson Y Szeto, Nimesh Desai, Eric E RoselliY Joseph Woo, Sreek Vemulapalli, John D Carroll, Pradeep Yadav, S Chris Malaisrie, Mark Russo, Tom C Nguyen, Tsuyoshi Kaneko, Gilbert Tang, Marc Ruel, Joanna Chikwe, Richard Lee, Robert H Habib, Isaac George, Martin B Leon, Michael J Mack

Research output: Contribution to journal › Article › peer-review

Abstract

BACKGROUND: The relationship between institutional volume and operative mortality after surgical aortic valve replacement (SAVR) remains unclear.

METHODS: From January 2013 to June 2018, 234 556 patients underwent isolated SAVR (n = 144 177) or SAVR with coronary artery bypass grafting (CABG) (n = 90 379) within the Society of Thoracic Surgeons Adult Cardiac Surgery Database. The association between annualized SAVR volume (group 1 [1-25 SAVRs], group 2 [26-50 SAVRs], group 3 [51-100 SAVRs], and group 4 [>100 SAVRs]) and operative mortality and composite major morbidity or mortality was assessed. Random effects models were used to evaluate whether historical (2013-2015) SAVR volume or risk-adjusted outcomes explained future (2016-2018) risk-adjusted outcomes.

RESULTS: The annualized median number of SAVRs per site was 35 (interquartile range, 22-59; isolated aortic valve replacement [AVR], 20; AVR with CABG, 13). Among isolated SAVR cases, the mean operative mortality and composite morbidity or mortality were 1.5% and 9.7%, respectively, at the highest-volume sites (group 4), with significantly higher rates among progressively lower-volume groups (P trend < .001). After adjustment, lower-volume centers had increased odds of operative mortality (group 1 vs group 4 [reference]: adjusted odds ratio [AOR] for SAVR, 2.24 [95% CI, 1.91-2.64]; AOR for SAVR with CABG, 1.96 [95% CI, 1.67-2.30]) and major morbidity or mortality (AOR for SAVR, 1.53 [95% CI, 1.39-1.69]; AOR for SAVR with CABG, 1.46 [95% CI, 1.32-1.61]) compared with the highest-volume institutions. Substantial variation in outcomes was observed across hospitals within each volume category, and prior outcomes explained a greater proportion of hospital operative outcomes than did prior volume.

CONCLUSIONS: Operative outcomes after SAVR with or without CABG is inversely associated with institutional procedure volumes; however, prior outcomes are more predictive of future outcomes than is prior volume. Given the excellent outcomes observed at many lower-volume hospitals, procedural outcomes may be preferable to procedural volumes as a quality metric.

Original language	English
Pages (from-to)	1299-1306
Number of pages	8
Journal	The Annals of thoracic surgery
Volume	114
Issue number	4
DOIs	https://doi.org/10.1016/j.athoracsur.2021.06.095
State	Published - Sep 2022
Externally published	Yes

Keywords

Aortic Valve/surgery
Aortic Valve Stenosis
Heart Valve Prosthesis
Heart Valve Prosthesis Implantation/methods
Humans
Risk Factors
Transcatheter Aortic Valve Replacement/adverse effects
Treatment Outcome

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10.1016/j.athoracsur.2021.06.095

Cite this

Thourani, V. H., Brennan, J. M., Edelman, J. J., Thibault, D., Jawitz, O. K., Bavaria, J. E., Higgins, R. S. D., Sabik, J. F., Prager, R. L., Dearani, J. A., MacGillivray, T. E., Badhwar, V., Svensson, L. G., Reardon, M. J., Shahian, D. M., Jacobs, J. P., Ailawadi, G., Szeto, W. Y., Desai, N., ... Mack, M. J. (2022). Association of Volume and Outcomes in 234 556 Patients Undergoing Surgical Aortic Valve Replacement. The Annals of thoracic surgery, 114(4), 1299-1306. https://doi.org/10.1016/j.athoracsur.2021.06.095

Thourani, VH, Brennan, JM, Edelman, JJ, Thibault, D, Jawitz, OK, Bavaria, JE, Higgins, RSD, Sabik, JF, Prager, RL, Dearani, JA, MacGillivray, TE, Badhwar, V, Svensson, LG, Reardon, MJ, Shahian, DM, Jacobs, JP, Ailawadi, G, Szeto, WY, Desai, N, Roselli, EE, Woo, YJ, Vemulapalli, S, Carroll, JD, Yadav, P, Malaisrie, SC, Russo, M, Nguyen, TC, Kaneko, T, Tang, G, Ruel, M, Chikwe, J, Lee, R, Habib, RH, George, I, Leon, MB & Mack, MJ 2022, 'Association of Volume and Outcomes in 234 556 Patients Undergoing Surgical Aortic Valve Replacement', The Annals of thoracic surgery, vol. 114, no. 4, pp. 1299-1306. https://doi.org/10.1016/j.athoracsur.2021.06.095

@article{f6462175a193461fb147fb8d15289b40,

title = "Association of Volume and Outcomes in 234 556 Patients Undergoing Surgical Aortic Valve Replacement",

abstract = "BACKGROUND: The relationship between institutional volume and operative mortality after surgical aortic valve replacement (SAVR) remains unclear.METHODS: From January 2013 to June 2018, 234 556 patients underwent isolated SAVR (n = 144 177) or SAVR with coronary artery bypass grafting (CABG) (n = 90 379) within the Society of Thoracic Surgeons Adult Cardiac Surgery Database. The association between annualized SAVR volume (group 1 [1-25 SAVRs], group 2 [26-50 SAVRs], group 3 [51-100 SAVRs], and group 4 [>100 SAVRs]) and operative mortality and composite major morbidity or mortality was assessed. Random effects models were used to evaluate whether historical (2013-2015) SAVR volume or risk-adjusted outcomes explained future (2016-2018) risk-adjusted outcomes.RESULTS: The annualized median number of SAVRs per site was 35 (interquartile range, 22-59; isolated aortic valve replacement [AVR], 20; AVR with CABG, 13). Among isolated SAVR cases, the mean operative mortality and composite morbidity or mortality were 1.5\% and 9.7\%, respectively, at the highest-volume sites (group 4), with significantly higher rates among progressively lower-volume groups (P trend < .001). After adjustment, lower-volume centers had increased odds of operative mortality (group 1 vs group 4 [reference]: adjusted odds ratio [AOR] for SAVR, 2.24 [95\% CI, 1.91-2.64]; AOR for SAVR with CABG, 1.96 [95\% CI, 1.67-2.30]) and major morbidity or mortality (AOR for SAVR, 1.53 [95\% CI, 1.39-1.69]; AOR for SAVR with CABG, 1.46 [95\% CI, 1.32-1.61]) compared with the highest-volume institutions. Substantial variation in outcomes was observed across hospitals within each volume category, and prior outcomes explained a greater proportion of hospital operative outcomes than did prior volume.CONCLUSIONS: Operative outcomes after SAVR with or without CABG is inversely associated with institutional procedure volumes; however, prior outcomes are more predictive of future outcomes than is prior volume. Given the excellent outcomes observed at many lower-volume hospitals, procedural outcomes may be preferable to procedural volumes as a quality metric.",

keywords = "Aortic Valve/surgery, Aortic Valve Stenosis, Heart Valve Prosthesis, Heart Valve Prosthesis Implantation/methods, Humans, Risk Factors, Transcatheter Aortic Valve Replacement/adverse effects, Treatment Outcome",

author = "Thourani, \{Vinod H\} and Brennan, \{James M\} and Edelman, \{J James\} and Dylan Thibault and Jawitz, \{Oliver K\} and Bavaria, \{Joseph E\} and Higgins, \{Robert S D\} and Sabik, \{Joseph F\} and Prager, \{Richard L\} and Dearani, \{Joseph A\} and MacGillivray, \{Thomas E\} and Vinay Badhwar and Svensson, \{Lars G\} and Reardon, \{Michael J\} and Shahian, \{David M\} and Jacobs, \{Jeffrey P\} and Gorav Ailawadi and Szeto, \{Wilson Y\} and Nimesh Desai and Roselli, \{Eric E\} and Woo, \{Y Joseph\} and Sreek Vemulapalli and Carroll, \{John D\} and Pradeep Yadav and Malaisrie, \{S Chris\} and Mark Russo and Nguyen, \{Tom C\} and Tsuyoshi Kaneko and Gilbert Tang and Marc Ruel and Joanna Chikwe and Richard Lee and Habib, \{Robert H\} and Isaac George and Leon, \{Martin B\} and Mack, \{Michael J\}",

year = "2022",

month = sep,

doi = "10.1016/j.athoracsur.2021.06.095",

language = "English",

volume = "114",

pages = "1299--1306",

journal = "The Annals of thoracic surgery",

issn = "0003-4975",

number = "4",

}

TY - JOUR

T1 - Association of Volume and Outcomes in 234 556 Patients Undergoing Surgical Aortic Valve Replacement

AU - Thourani, Vinod H

AU - Brennan, James M

AU - Edelman, J James

AU - Thibault, Dylan

AU - Jawitz, Oliver K

AU - Bavaria, Joseph E

AU - Higgins, Robert S D

AU - Sabik, Joseph F

AU - Prager, Richard L

AU - Dearani, Joseph A

AU - MacGillivray, Thomas E

AU - Badhwar, Vinay

AU - Svensson, Lars G

AU - Reardon, Michael J

AU - Shahian, David M

AU - Jacobs, Jeffrey P

AU - Ailawadi, Gorav

AU - Szeto, Wilson Y

AU - Desai, Nimesh

AU - Roselli, Eric E

AU - Woo, Y Joseph

AU - Vemulapalli, Sreek

AU - Carroll, John D

AU - Yadav, Pradeep

AU - Malaisrie, S Chris

AU - Russo, Mark

AU - Nguyen, Tom C

AU - Kaneko, Tsuyoshi

AU - Tang, Gilbert

AU - Ruel, Marc

AU - Chikwe, Joanna

AU - Lee, Richard

AU - Habib, Robert H

AU - George, Isaac

AU - Leon, Martin B

AU - Mack, Michael J

PY - 2022/9

Y1 - 2022/9

N2 - BACKGROUND: The relationship between institutional volume and operative mortality after surgical aortic valve replacement (SAVR) remains unclear.METHODS: From January 2013 to June 2018, 234 556 patients underwent isolated SAVR (n = 144 177) or SAVR with coronary artery bypass grafting (CABG) (n = 90 379) within the Society of Thoracic Surgeons Adult Cardiac Surgery Database. The association between annualized SAVR volume (group 1 [1-25 SAVRs], group 2 [26-50 SAVRs], group 3 [51-100 SAVRs], and group 4 [>100 SAVRs]) and operative mortality and composite major morbidity or mortality was assessed. Random effects models were used to evaluate whether historical (2013-2015) SAVR volume or risk-adjusted outcomes explained future (2016-2018) risk-adjusted outcomes.RESULTS: The annualized median number of SAVRs per site was 35 (interquartile range, 22-59; isolated aortic valve replacement [AVR], 20; AVR with CABG, 13). Among isolated SAVR cases, the mean operative mortality and composite morbidity or mortality were 1.5% and 9.7%, respectively, at the highest-volume sites (group 4), with significantly higher rates among progressively lower-volume groups (P trend < .001). After adjustment, lower-volume centers had increased odds of operative mortality (group 1 vs group 4 [reference]: adjusted odds ratio [AOR] for SAVR, 2.24 [95% CI, 1.91-2.64]; AOR for SAVR with CABG, 1.96 [95% CI, 1.67-2.30]) and major morbidity or mortality (AOR for SAVR, 1.53 [95% CI, 1.39-1.69]; AOR for SAVR with CABG, 1.46 [95% CI, 1.32-1.61]) compared with the highest-volume institutions. Substantial variation in outcomes was observed across hospitals within each volume category, and prior outcomes explained a greater proportion of hospital operative outcomes than did prior volume.CONCLUSIONS: Operative outcomes after SAVR with or without CABG is inversely associated with institutional procedure volumes; however, prior outcomes are more predictive of future outcomes than is prior volume. Given the excellent outcomes observed at many lower-volume hospitals, procedural outcomes may be preferable to procedural volumes as a quality metric.

AB - BACKGROUND: The relationship between institutional volume and operative mortality after surgical aortic valve replacement (SAVR) remains unclear.METHODS: From January 2013 to June 2018, 234 556 patients underwent isolated SAVR (n = 144 177) or SAVR with coronary artery bypass grafting (CABG) (n = 90 379) within the Society of Thoracic Surgeons Adult Cardiac Surgery Database. The association between annualized SAVR volume (group 1 [1-25 SAVRs], group 2 [26-50 SAVRs], group 3 [51-100 SAVRs], and group 4 [>100 SAVRs]) and operative mortality and composite major morbidity or mortality was assessed. Random effects models were used to evaluate whether historical (2013-2015) SAVR volume or risk-adjusted outcomes explained future (2016-2018) risk-adjusted outcomes.RESULTS: The annualized median number of SAVRs per site was 35 (interquartile range, 22-59; isolated aortic valve replacement [AVR], 20; AVR with CABG, 13). Among isolated SAVR cases, the mean operative mortality and composite morbidity or mortality were 1.5% and 9.7%, respectively, at the highest-volume sites (group 4), with significantly higher rates among progressively lower-volume groups (P trend < .001). After adjustment, lower-volume centers had increased odds of operative mortality (group 1 vs group 4 [reference]: adjusted odds ratio [AOR] for SAVR, 2.24 [95% CI, 1.91-2.64]; AOR for SAVR with CABG, 1.96 [95% CI, 1.67-2.30]) and major morbidity or mortality (AOR for SAVR, 1.53 [95% CI, 1.39-1.69]; AOR for SAVR with CABG, 1.46 [95% CI, 1.32-1.61]) compared with the highest-volume institutions. Substantial variation in outcomes was observed across hospitals within each volume category, and prior outcomes explained a greater proportion of hospital operative outcomes than did prior volume.CONCLUSIONS: Operative outcomes after SAVR with or without CABG is inversely associated with institutional procedure volumes; however, prior outcomes are more predictive of future outcomes than is prior volume. Given the excellent outcomes observed at many lower-volume hospitals, procedural outcomes may be preferable to procedural volumes as a quality metric.

KW - Aortic Valve/surgery

KW - Aortic Valve Stenosis

KW - Heart Valve Prosthesis

KW - Heart Valve Prosthesis Implantation/methods

KW - Humans

KW - Risk Factors

KW - Transcatheter Aortic Valve Replacement/adverse effects

KW - Treatment Outcome

U2 - 10.1016/j.athoracsur.2021.06.095

DO - 10.1016/j.athoracsur.2021.06.095

M3 - Article

C2 - 34785247

SN - 0003-4975

VL - 114

SP - 1299

EP - 1306

JO - The Annals of thoracic surgery

JF - The Annals of thoracic surgery

IS - 4

ER -