‘Home Time’ Validated as TAVI Outcomes Performance Metric
Patients who were alive and well at home in the first 30 days had lower mortality and readmission than those with longer stays.
More days spent at home in the 30 days after TAVI, rather than in a hospital or care facility, is a predictor of lower mortality and readmission rates over time, a new study suggests. Used as an outcomes metric, home time could complement other currently used measures of hospital performance such as TAVI volume, the researchers say.
An important feature of home time is that it is easily understandable by patients and is more intuitive than other measures in assessing hospital performance, lead author Amgad Mentias, MD (Cleveland Clinic Foundation, OH), told TCTMD in an email. Previously, the 30-day home-time metric has been shown to be a strong predictor of mortality and readmission in patients with heart failure and acute MI, but it had not been tested in TAVI care.
In their study, published January 10, 2022, in the Journal of the American College of Cardiology, Mentias and colleagues found that mortality and readmission at 30 days and 1 year were inversely correlated with 30-day, risk-adjusted home time.
“Knowing the home time after TAVR for a specific hospital puts this patient-centered approach in the front and center, and helps clinicians and hospitals strive to achieve care that leads to improvement in outcomes that are most meaningful to the patients,” Mentias noted.
In an accompanying editorial, Matthew W. Sherwood, MD (Inova Heart and Vascular Institute, Falls Church, VA), and Amit N. Vora, MD (University of Pennsylvania Medical Center Heart and Vascular Institute, Harrisburg, PA), agree that home time is “a simple, transparent, intuitive metric that is understandable to both institutions and patients alike.” Moving forward, they add, “stakeholders from both the provider and patient domains should be brought together to establish composite metrics (including novel measures such as 30-day home time) that better align the needs of all parties.”
Mentias et al assessed outcomes for 160,792 Medicare patients from 652 centers who underwent an elective TAVI between 2015 and 2019. Hospitals were stratified in quartiles by 30-day, risk-adjusted home time. Quartile 1 (Q1) represented the lowest performing hospitals, and quartile 4 (Q4) the highest performing.
Increasing 30-day home time correlated with lower in-hospital mortality (Q1: 1.40% vs Q4: 0.76%), 30-day mortality (Q1: 2.31% vs Q4: 1.37%), 30-day readmission (Q1: 14.36% vs Q4: 10.80%), and 30-day composite clinical outcome (Q1: 4.94%, Q4: 3.56%; P < 0.01 for all). Longer term, there was a similar inverse correlation for 1-year mortality (Q1: 11.58% vs Q4: 9.47%) and 1-year all-cause readmission (Q1: 45.78% vs Q4: 41.31%; P < 0.001 for both).
Length of hospital stay after TAVI (46.4%) and skilled nursing facility stay (25.4%) were the most frequent reasons for loss of days from home time within the 30-day period. According to the authors, patients losing home time for these reasons are likely to be those with a high burden of comorbidities, poor functional status, and increased frailty burden. Individual-center TAVI volume was not significantly correlated with risk-adjusted, 30-day home time (P = 0.90).
Across centers, home time as a metric resulted in shifting and reclassification of some hospitals’ performance status: upgrading some, while downgrading others.
Incentivizing and Downstream Consequences
To TCTMD, Mentias said no single metric is perfect, including this one, which is why he sees it as complementary.
“When hospital performance is assessed using multiple metrics, we get a better picture of overall care and the limitations of one metric can be covered for by the other,” he said.
There is a theorical risk that home time could incentivize some hospitals to perform TAVI preferentially in lower-risk patients or send home patients who could benefit from skilled nursing facilities or long-term acute care centers. However, Mentis said the comprehensive nature of the metric used alongside others “would disincentivize such approaches as these would lead to higher chances of readmission or adverse outcomes that will contribute to loss of home time.” Instead, he and his colleagues believe that using the metric could actually incentivize TAVI centers to be more judicious in using those types of facilities, potentially partnering with—and sharing accountability with—higher-performing ones to ensure continuity of quality care.
“As with any outcome measure, it will be important to track progress and continually refine the metric to achieve the stated objectives and to minimize unwarranted downstream consequences,” caution Sherwood and Vora. Of concern, growing evidence that robust public reporting of hospital metrics contributes to risk aversion among some operators.
“If this practice pattern were translated to TAVR, there could be significant consequences for older adults and frail patients’ access to care,” they add.
Mentias A, Keshvani N, Desai MY, et al. Risk-adjusted, 30-day home time after transcatheter aortic valve replacement as a hospital-level performance metric. J Am Coll Cardiol. 2022;79:132-144.
Sherwood MW, Vora AN. For TAVR, home is where the heart is. J Am Coll Cardiol. 2022;79:145-147.
- Mentias reports no relevant conflicts of interest.
- Sherwood reports honoraria/consulting fees from Medtronic and Boston Scientific.
- Vora reports consulting fees from Medtronic.