Inter-hospital transfer (IHT) of patients has been shown to be associated with higher mortality and worse outcomes in critically ill patients. Transcatheter aortic valve replacement (TAVR) continues to become more widely utilized in managing severe aortic stenosis for surgically high-risk or inoperable patients. The association between TAVR outcomes and IHT has not yet been explored. This study aimed to evaluate the impact of IHT on TAVR outcomes.
We identified patients receiving non-elective TAVR without prior or concomitant cardiac surgery using the 2012-2015 National Readmissions Database (NRD), an all-payer hospitalization database. All patients were categorized as either IHT or non-IHT. Univariate analysis and multivariable regression were used to compare index and 30-day readmission outcomes, including mortality, complications (e.g. cardiovascular, thromboembolic, and respiratory adverse events), hospitalization costs, and length of stay (LOS) for IHT and non-IHT patients. Furthermore, readmission cause was categorically compared between IHT and non-IHT patients.
Of the 8,702 overall non-elective TAVR sample patients, 1,443 (16.6%) were categorized as IHT and 7,259 (83.4%) as non-IHT. On average, the IHT patients were of similar age but had a higher Elixhauser Comorbidity Index (7.6 vs 6.5, P<0.001). IHT patients also had higher unadjusted index complication incidence (76.4 vs 57.0%, P<0.001), length of stay (20.6 vs 12.5 days, p<0.001), and hospitalization cost ($88,322 vs 66,613, p<0.001) along with an increased 30-day readmission rate (25.7 vs 18.6%, P<0.001) compared to non-IHT patients. Furthermore, IHT patients had a higher prevalence of cardiac readmissions (50.8 vs 40.7%, P=0.040), specifically due to heart failure (26.4 vs 17.7%, P=0.016). After adjusting for patient and hospital characteristics, IHT was associated with higher odds of index complications (OR 1.96, 95% CI: 1.55-2.47) and 30-day readmission (OR 1.34, 95% CI 1.09-1.64), but similar index (OR 0.91, 95% CI 0.59-1.40) and readmission (OR 0.74, 95% CI 0.32-1.74) mortality. IHT was also associated with increased index LOS (5.4 days, 95% CI 4.4-6.4) and hospitalization costs ($13,514, 95% CI 10,071-16,958).
In this nationwide study, transfer of TAVR patients was independently associated with increased complications, resource utilization, and readmission but not mortality. More IHT TAVR patients were readmitted due to cardiac causes, which may be an indicator of care fragmentation. Awareness of the negative impact of IHT in the TAVR population could be considered during the care of TAVR candidates and the establishment of minimum volume requirements for TAVR centers. Risks associated with IHT in the TAVR population should be carefully weighed in patient selection and referral.