Effect of Clinical Trial Experience on Transcatheter Aortic Valve Replacement Outcomes.
BACKGROUND
Transcatheter aortic valve replacement (TAVR) was approved by the Food and Drug Administration (FDA) in November 2011 after a collaborative technology development process involving professional medical societies, the medical device industry, and the FDA. After FDA approval, TAVR was adopted by numerous hospitals that had not participated in TAVR clinical trials. It is uncertain if outcomes at these hospitals were comparable with those at clinical trial hospitals.


RESULTS
All patients with Medicare physician claims for TAVR between January 1, 2011, and November 30, 2012, were identified, and postoperative mortality was assessed using Medicare enrollment data. Risk-adjusted mortality was calculated via a multivariable model that adjusted for demographics and comorbidities. We identified 5009 patients who underwent TAVR, with 3617 TAVRs performed at 68 hospitals that had participated in clinical trials and 1392 TAVRs performed at 140 nontrial hospitals. The preoperative characteristics of patients at trial versus nontrial hospitals were similar. There were no significant differences in risk-adjusted 30-day mortality (5.9% versus 5.6%, odds ratio, 0.88; 95% confidence interval, 0.66-1.15; P=0.34) or 180-day mortality (16.5% versus 15.8%, odds ratio, 0.99; 95% confidence interval, 0.75-1.3; P=0.94).


CONCLUSIONS
Patients undergoing TAVR at nontrial hospitals had comparable clinical outcomes to patients undergoing TAVR at clinical trial hospitals. This finding contrasts with several other cardiovascular devices and procedures for which higher mortality was observed at hospitals that did not participate in clinical trials. The unique policy and regulatory environment governing TAVR adoption by hospitals may have contributed to better outcomes during the technology diffusion process.
From the Leonard Davis Institute of Health Economics (F.H.M., P.W.G., N.D.D.), Division of Cardiovascular Surgery, Perelman School of Medicine (F.H.M., D.K., K.M.M., N.D.D.), and Department of Medicine, Perelman School of Medicine (P.W.G, C.W.), University of Pennsylvania, Philadelphia; and Philadelphia Veterans Affairs Medical Center's Center for Health Equity Research and Promotion, PA (P.W.G).
Fenton H
FH
McCarthy
From the Leonard Davis Institute of Health Economics (F.H.M., P.W.G., N.D.D.), Division of Cardiovascular Surgery, Perelman School of Medicine (F.H.M., D.K., K.M.M., N.D.D.), and Department of Medicine, Perelman School of Medicine (P.W.G, C.W.), University of Pennsylvania, Philadelphia; and Philadelphia Veterans Affairs Medical Center's Center for Health Equity Research and Promotion, PA (P.W.G).
Peter W
PW
Groeneveld
From the Leonard Davis Institute of Health Economics (F.H.M., P.W.G., N.D.D.), Division of Cardiovascular Surgery, Perelman School of Medicine (F.H.M., D.K., K.M.M., N.D.D.), and Department of Medicine, Perelman School of Medicine (P.W.G, C.W.), University of Pennsylvania, Philadelphia; and Philadelphia Veterans Affairs Medical Center's Center for Health Equity Research and Promotion, PA (P.W.G).
Dale
D
Kobrin
From the Leonard Davis Institute of Health Economics (F.H.M., P.W.G., N.D.D.), Division of Cardiovascular Surgery, Perelman School of Medicine (F.H.M., D.K., K.M.M., N.D.D.), and Department of Medicine, Perelman School of Medicine (P.W.G, C.W.), University of Pennsylvania, Philadelphia; and Philadelphia Veterans Affairs Medical Center's Center for Health Equity Research and Promotion, PA (P.W.G).
Katherine M
KM
McDermott
From the Leonard Davis Institute of Health Economics (F.H.M., P.W.G., N.D.D.), Division of Cardiovascular Surgery, Perelman School of Medicine (F.H.M., D.K., K.M.M., N.D.D.), and Department of Medicine, Perelman School of Medicine (P.W.G, C.W.), University of Pennsylvania, Philadelphia; and Philadelphia Veterans Affairs Medical Center's Center for Health Equity Research and Promotion, PA (P.W.G).
Christopher
C
Wirtalla
From the Leonard Davis Institute of Health Economics (F.H.M., P.W.G., N.D.D.), Division of Cardiovascular Surgery, Perelman School of Medicine (F.H.M., D.K., K.M.M., N.D.D.), and Department of Medicine, Perelman School of Medicine (P.W.G, C.W.), University of Pennsylvania, Philadelphia; and Philadelphia Veterans Affairs Medical Center's Center for Health Equity Research and Promotion, PA (P.W.G). Nimesh.Desai@uphs.upenn.edu.
Nimesh D
ND
Desai
D000368:Aged; D000369:Aged, 80 and over; D002986:Clinical Trials as Topic; D005260:Female; D006801:Humans; D059032:Learning Curve; D008297:Male; D006278:Medicare; D010359:Patient Readmission / Q000706:statistics & numerical data; D011183:Postoperative Complications / Q000453:epidemiology; D012189:Retrospective Studies; D020521:Stroke / Q000453:epidemiology; D065467:Transcatheter Aortic Valve Replacement / Q000401:mortality*; D014481:United States / Q000453:epidemiology
aortic valve stenosis; clinical trial; comorbidity; medicare; transcatheter aortic valve replacement