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Optimising organisational efficiencies in the treatment of patients with severe, symptomatic aortic stenosis

The TAVI approach is a driver for organisational benefits, including shorter waiting lists, cuts to procedural times, increase in hospital capacity and shorter length of hospital stay.

About this topic

The Edwards SAPIEN 3TM Transcatheter Heart Valve (THV) is eligible for use in all-risk patients,1–3 and it is expected that this will significantly increase the number of patients who will be treated with this minimally invasive procedure, with major implications for healthcare resource planning.4

Acute care institutions around the world have been reconfigured in response to the COVID-19 pandemic. As we enter the next phase, the priority will be addressing the backlog of patients whose care has been placed on hold. It has never been more critical that a hospital display maximum efficiency in delivering best clinical care to their patients – from shortening waiting lists and length of stay (LOS) to lowering re-hospitalisation rates. A key focus will be on patients with aortic stenosis.

There is a proven need to increase hospital efficiencies, including lowering in-hospital complications to improve outcomes for patients as well as increasing access to beds for other patients.5 More importantly, improved efficiency and lower complication rates will improve patient waiting times: studies have shown that increased patient times can affect patient mortality and morbidity while patients wait for intervention.6–8

What are the possible impacts on the hospital’s efficiencies?

  • Shorter procedure time
Procedure time (in minutes) has been shown to be reduced from 208.3 for surgical aortic valve replacement to 58.6 for TAVI9
  • Lower rates of complications
In-hospital complications lead to organisational inefficiencies, such as increased LOS consumption of additional resources and blocked access to hospital beds for other patients. This adds to the hospital’s increased expenditure (which can be large) for additional nursing time, diagnostics, and pharmaceuticals before possible discharge.5 A shorter, complication-free patient pathway optimises staff requirements and facility use.10
  • Reduced LOS without compromising safety
Because the SAPIEN 3TM TAVI procedure is less invasive with fewer clinical complications than surgery, both median intensive care time and median total LOS are reported to be lower than SAVR.9 LOS was reported to be 3 and 7 days for TAVI and SAVR, respectively.9 Several single-centre studies have shown that discharge time less than 72h is safe and feasible after transfemoral (TF) TAVI:11 55.1% of TF TAVI patients from the TVT registry were discharged within 72h12, and 96% of TF TAVI patients from the PARTNER 3TM trial were discharged within 30 days compared with 73% of surgical patients1. Over the last decade, the duration of hospitalisation after TAVI has steadily decreased.12 In the 2019 multicentre European FAST-TAVI trial, the median LOS was 2 days: 26.8% were discharged within 1 day, 51% within 2 days and 72.6% within 3 days. The majority of patients were discharged home.13 Across the EU, the mean LOS for TAVI patients ranges from 5 (France)14 to 14.5 (Germany) (data on file, Edwards Lifesciences). The UK mean is reported to be 5.5.15
  • Reduced rate of re-hospitalisation1,16,17
Readmission after cardiac procedures is common and contributes to increased healthcare use.16 The primary cause of cardiac re-hospitalisation is heart failure,16 for which the median LOS is 4 days.17 Awareness of the predictors of re-admission following the TAVI procedure can help target high-risk patients for intervention to reduce readmission.
  • Less demand for rehabilitation beds, resulting in shorter waiting lists
This gives the organisation the option of either redeploying staff or treating more patients.

Consolidating these hospital efficiencies, the results of the Vancouver 3M TAVI Study has demonstrated that a minimalist, streamlined TAVI pathway with the Edwards Lifesciences SAPIEN 3TM valve, with rapid remobilisation, allows for next-day discharge home, with reproducible, excellent safety and efficiency outcomes.18

Consequently, in the hospital, the TAVI-led efficiencies in the management of ssAS patients may have a significant economic benefit when the patient pathway is optimised. As demonstrated in the 3M TAVI study,18 optimising the patient pathway has benefits for the hospital such as early discharge and excellent patient outcomes, which ultimately, might lead to financial benefits, improved waiting lists and less demand for beds.

Optimising the patient pathway as outlined above will be crucial during and post-COVID-19. As all hospital resources will have been redistributed in order to tackle the current pandemic, a lot of patient care has been placed on hold. Tackling this backlog becomes of the utmost importance, and the TAVI-led efficiencies with the Edwards Lifesciences SAPIEN 3TM valve can support optimising hospital efficiency with this.

 

  1. Mack MJ, et al. Transcatheter aortic-valve replacement with a balloon-expandable valve in low-risk patients. N Engl J Med 2019;380:1695–705.
  2. Leon MB, et al. Transcatheter or surgical aortic-valve replacement in intermediate-risk patients. N Engl J Med 2016;374:1609–20.
  3. Smith CR, et al. Transcatheter versus surgical aortic-valve replacement in high-risk patients. N Engl J Med 2011;364:2187–98.
  4. Durko AP, et al. Annual number of candidates for transcatheter aortic valve implantation per country: current estimates and future projections. Eur Heart J 2018;0:1-8.
  5. Lagoe RJ and Westert GP. Evaluation of hospital inpatient complications: a planning approach. BMC Health Services Research 2010;10:200.
  6. Bhattacharyya S. Mortality whilst waiting for intervention in symptomatic severe aortic ste Europe Heart Journal – Quality of Care and Clinical Outcomes 2020;6:89–90.
  7. Elbaz-Greener G, et al. Temporal trends and clinical consequences of wait times for transcatheter aortic valve replacement. Circulation 2018;138:483–93.
  8. Malaisrie SC, et al. Mortality while waiting for aortic valve replacement. Anne Thorac Surg 2014;98:1564–70.
  9. Mack MJ, et al. Transcatheter aortic-valve replacement with a balloon-expandable valve in low-risk patients [supplemental appendix]. N Engl J Med 2019;380:1695–705.
  10. Gutman A, et al. Analysis of the Additional Costs of Clinical Complications in Patients Undergoing Transcatheter Aortic Valve Replacement in the German Health Care System. Int J Cardiol 2015;179:231–23.
  11. Wayangankar SA, et al. Length of stay after transfemoral transcatheter aortic valve replacement: An analysis of the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry. JACC Cardiovasc Interv 2019;12:422–30.
  12. Barbanti M, et al. Early discharge after transfemoral transcatheter aortic valve implantation. Heart 2015;101:1485–90.
  13. Barbanti M, et al. Optimising patient discharge management after transfemoral transcatheter aortic valve implantation: the multicentre European FAST-TAVI trial. Euro Intervention 2019;15:147–54.
  14. Gilard M. Activité Structurelle en 2018, High Tech 2019. Available from http://www.hightech-cardio.org/usrfile/Presentation/2019/OC-IN009.pdf. Accessed April 2020.
  15. Ludman P, Transcatheter Aortic Valve Implantation UK TAVI Audit Data 2007 to 2017. Available from: http://www.bcis.org.uk/wp-content/uploads/2018/11/TAVI-slide-deck-to-2017-data-15-11-2018.pdf. Accessed April 2020
  16. Kolte D, et al. Thirty-Day Readmissions After Transcatheter Aortic Valve Replacement in the United States: Insights From the Nationwide Readmissions Database. Circ Cardiovasc Interv 2017;10:e004472.
  17. Tashtish N, et al. Length of Stay and Hospital Charges for Heart Failure Admissions in the United States: Analysis of the National Inpatient Sample. J Cardiac Failure 2017;23:8 Supplement 1 (S59).
  18. Wood DA, et al. The Vancouver 3M (Multidisciplinary, Multimodality, But Minimalist) Clinical Pathway Facilitates Safe Next-Day Discharge Home of Low-, Medium-, and High-Volume Transfemoral Transcatheter Aortic Valve Replacement Centres. JACC Cardiovasc Interv 2019;12:459–69.
 
This content is sponsored by Edwards Lifesciences