Optimising organisational efficiencies in the treatment of patients with severe, symptomatic aortic stenosis
Eligible TAVI population and a backlog of care
Healthcare organisations have been reconfigured in response to the COVID-19 pandemic, including cancellations of elective procedures, which has resulted in one of the largest official waiting lists on record. There were 4.5 million patients waiting to complete treatment as of December 2020, with 4.7 million fewer completed patient pathways in 2020 vs 2019. Additionally, with 5.9 million referrals fewer in 2020 compared with 2019, there is the concept of the ‘hidden’ waiting list since many of these patients will still require treatment.1
Along with Edwards SAPIEN 3TM Transcatheter Heart Valve (THV) being CE-marked for use in all-risk patients,2-5 and increasing the number of patients eligible for TAVI as a consequence,6 the ongoing COVID-19 pandemic is undoubtedly adding to the increasing ssAS patient population who are eligible for TAVI.7
As COVID-19 restrictions are lifted, the priority for healthcare organisations will be to address the backlog of patients whose care has been placed on hold,8 and TAVI treatment for patients with ssAS has unique organisational benefits that will help healthcare organisations improve organisational efficiency with derivative economic benefits.7
It has been reported that during the peak of the pandemic, ssAS patients who were previously accepted for SAVR were being reconsidered for TAVI.7 Given the increased demand on healthcare resources during the pandemic, TAVI offers unique organisational advantages over SAVR since it is minimally invasive with lower complication rates, enabling faster recovery, shorter length of stay and conservation of resources;7,9 during the pandemic, clinical practice was guided by the large and well-established evidence base of TAVI in patients with severe aortic stenosis.10
Therefore, the COVID-19 pandemic has highlighted the organisational and patient benefits of TAVI vs SAVR. The clinical practice changes observed during the pandemic were based on well-established evidence of TAVI vs SAVR gained outside of a global pandemic environment; this suggests that the pandemic highlighted the existing benefits of TAVI and that these benefits may well extend beyond the pandemic.7,9,10
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, 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.15
TAVI-led efficiencies with the Edwards Lifesciences SAPIEN 3™ valve can support hospitals with this, and the transition from SAVR to TAVI presents clear opportunities to improve organisational efficiency by: (1) minimising procedural time;5 (2) lowering the rates of complications5,16 (3) reducing the length of hospital stay without compromising safety;5,17 (4) reducing the rate of re-hospitalisation;5,18 (5) shortening waiting lists and (6) lessening demand on rehabilitation beds.
To counter the ever-increasing waiting list of patients,1 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.11 More importantly, improved efficiency and lower complication rates will improve patient waiting times: studies have shown that increased patient times can adversely affect patient mortality and morbidity while patients wait for intervention.12-14
Organisational and economic benefits
|Minimising procedural time|
Procedure time (in minutes) has been shown to be reduced from 208.3 for SAVR to 58.6 for TAVI.5
More patients can be treated daily in one cath-lab/hybrid room, or costs can be cut by reallocating/releasing staff.5
|Lowering the rates of complications|
In-hospital complications such as bleeding complications, severe kidney failure, and implantation of a second valve19 lead to inefficiencies, such as increased LOS consumption of additional resources and blocked access to hospital beds for other patients.11
This adds to the hospital’s expenditure for additional nursing time, diagnostics, and pharmaceuticals before possible discharge.11 Potential cost savings that result from lower complication rates compared with surgery have been quantified with the SAPIEN 3 valve at ~€40005,16,19
|Reducing the length of hospital stay without compromising safety|
LOS was reported to be 3 and 7 days for TAVI and SAVR, respectively.5,16 Studies report safe discharge home ≤72h in 73% of TAVI patients, with 27% of these ≤24h and 51% ≤ 48h20 Across the EU, the mean LOS for TAVI patients ranges from 5 (France)21 to 14.5 (Germany) (data on file, Edwards Lifesciences). The UK mean is reported to be 5.5.22
The TAVI minimalist approach limits direct procedural costs (estimated at a saving of ~€4000 over SAVR).5,16,23 More importantly, it shortens the median LOS (a saving of ~€1000 over SAVR for intensive care unit LOS, and ~€1900 for ward LOS,5,16,24 thereby minimising post-procedure costs.17
|Reducing the rate of re-hospitalisation|
Readmission after cardiac procedures is common and contributes to increased healthcare use.18 The primary cause of cardiac re-hospitalisation is heart failure,18 for which the median LOS is 4 days.25 The SAPIEN 3 valve leads to less hospitalisation at 30 days compared with SAVR, and it is the only TAVI system superior to SAVR for all-cause death, all stroke and re-hospitalisation at 1 year (8.5% versus 15.1%).5
Re-hospitalisation has hospital costs in terms of staff, beds and procedural resources and lowering re-hospitalisation rates allows these resources to be allocated elsewhere, increasing hospital efficiency, and lowering waiting lists, leading to better outcomes for patients.11
- 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.
- Leon MB, et al. Transcatheter or surgical aortic-valve replacement in intermediate-risk patients. N Engl J Med 2016;374:1609–20.
- Smith CR, et al. Transcatheter versus surgical aortic-valve replacement in high-risk patients. N Engl J Med 2011;364:2187–98.
- 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.
- Lagoe RJ and Westert GP. Evaluation of hospital inpatient complications: a planning approach. BMC Health Services Research 2010;10:200.
- 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.
- Elbaz-Greener G, et al. Temporal trends and clinical consequences of wait times for transcatheter aortic valve replacement. Circulation 2018;138:483–93.
- Malaisrie SC, et al. Mortality while waiting for aortic valve replacement. Anne Thorac Surg 2014;98:1564–70.
- 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.
- 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.
- 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.
- Barbanti M, et al. Early discharge after transfemoral transcatheter aortic valve implantation. Heart 2015;101:1485–90.
- 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.
- 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.
- 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
- 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.
- 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).
- 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.
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