Original Investigation |

Trends in Aortic Valve Replacement for Elderly Patients in the United States, 1999-2011

José Augusto Barreto-Filho, MD, PhD1,10; Yun Wang, PhD2,3,4; John A. Dodson, MD5; Mayur M. Desai, PhD, MPH6,7; Lissa Sugeng, MD, MPH4; Arnar Geirsson, MD8; Harlan M. Krumholz, MD, SM2,4,7,9
[+] Author Affiliations
1Division of Cardiology, Federal University of Sergipe, and the Clínica e Hospital São Lucas, Aracaju, Sergipe, Brazil
2Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
3Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts
4Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
5Division of Aging, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
6Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut
7Robert Wood Johnson Clinical Scholars Program, Yale University School of Medicine, New Haven, Connecticut
8Section of Cardiac Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
9Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
10Center for Outcomes Research and Evaluation at Yale-New Haven Hospital (during the time that the work was conducted)
JAMA. 2013;310(19):2078-2084. doi:10.1001/jama.2013.282437.
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Importance  There is a need to describe contemporary outcomes of surgical aortic valve replacement (AVR) as the population ages and transcatheter options emerge.

Objective  To assess procedure rates and outcomes of surgical AVR over time.

Design, Setting, and Participants  A serial cross-sectional cohort study of 82 755 924 Medicare fee-for-service beneficiaries undergoing AVR in the United States between 1999 and 2011.

Main Outcomes and Measures  Procedure rates for surgical AVR alone and with coronary artery bypass graft (CABG) surgery, 30-day and 1-year mortality, and 30-day readmission rates.

Results  The AVR procedure rate increased by 19 (95% CI, 19-20) procedures per 100 000 person-years over the 12-year period (P<.001), with an age-, sex-, and race-adjusted rate increase of 1.6% (95% CI, 1.0%-1.8%) per year. Mortality decreased at 30 days (absolute decrease, 3.4%; 95% CI, 3.0%-3.8%; adjusted annual decrease, 4.1%; 95% CI, 3.7%- 4.4%) per year and at 1 year (absolute decrease, 2.6%; 95% CI, 2.1%-3.2%; adjusted annual decrease, 2.5%; 95% CI, 2.3%-2.8%). Thirty-day all-cause readmission also decreased by 1.1% (95% CI, 0.9%-1.3%) per year. Aortic valve replacement with CABG surgery decreased, women and black patients had lower procedure and higher mortality rates, and mechanical prosethetic implants decreased, but 23.9% of patients 85 years and older continued to receive a mechanical prosthesis in 2011.

Conclusions and Relevance  Between 1999 and 2011, the rate of surgical AVR for elderly patients in the United States increased and outcomes improved substantially. Medicare data preclude the identification of the causes of the findings and the trends in procedure rates and outcomes cannot be causally linked. Nevertheless, the findings may be a useful benchmark for outcomes with surgical AVR for older patients eligible for surgery considering newer transcatheter treatments.

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