Economic Considerations in Access to Transcatheter Aortic Valve Replacement

Abstract

Transcatheter aortic valve replacement (TAVR) has revolutionized the treatment of aortic stenosis, with the number of procedures and sites offering the procedure steadily rising over the past decade in the United States. Despite this, growth into certain markets has been limited as hospitals have to balance high TAVR costs with the ability to offer a complete array of state-of-the-art therapies for aortic stenosis. This trade-off often results in decreased access to TAVR services by patients cared for in hospitals that cannot afford these services or have difficulty meeting procedural requirements, recruiting skilled physicians, and initiating and then maintaining a functioning TAVR program. The lack of access is more common among patients of color or those who are socioeconomically disadvantaged. The purpose of this review is to describe the hospital-level economic considerations of TAVR in the United States and the resulting effects on geographic, racial, ethnic, and socioeconomic access for Americans.

Racial, Ethnic, and Socioeconomic Inequities in Access to Left Atrial Appendage Occlusion

“…Drug‐eluting stents and TAVR, for example, have diffused faster in markets with higher degrees of competition between cardiology practices. 20 , 21 However, prior work has found that even within large, urban health systems where access to care is not geographically limited, Black and White patients may have differing attitudes toward medical innovation. This may be informed by socioeconomic factors and trust in the health care system and may explain differing propensities to accept novel, invasive treatments.…”

Inequities in Access to Structural Heart Disease Interventions

“…Volume requirements and mandatory ancillary services are implemented to ensure quality of outcomes, but recent research provides conflicting evidence on the utility of volume requirements as surrogates for quality. 2 Thus, regulatory agencies must strike the challenging balance of maintaining procedural quality while also providing equitable access to these high-technology procedures. Site-level administrative burdens may hamper decentralization of structural heart services to smaller community hospitals.…”

“…These inequities arise from various factors, including structural racism, and are shaped by the intersectionality of environmental, legal, and social elements . Historically, there has been decreased application of novel cardiovascular therapies among patients who are Black or Latinx or from socioeconomically disadvantaged groups . Consistent with reduced access to cardiovascular therapies, previous work has found associations of race, ethnicity, and socioeconomic status with reduced use of structural heart disease interventions.…”

“…In addition, regulatory agencies identify site-level requirements for TAVR and other structural heart programs. Volume requirements and mandatory ancillary services are implemented to ensure quality of outcomes, but recent research provides conflicting evidence on the utility of volume requirements as surrogates for quality . Thus, regulatory agencies must strike the challenging balance of maintaining procedural quality while also providing equitable access to these high-technology procedures.…”

Did the COVID-19 Pandemic Just Turn TAVR Into an Outpatient Procedure?

“… 13 Many of the improvements in TAVR efficiency have been successful at chipping away at the remaining hospital costs allowing efficient hospitals adopting these practices to realize a modest contribution margin from their TAVR programs. 14 However, if outpatient coding that reimburses significantly lower than current inpatient diagnosis-related group codes were to emerge for TAVR, this would actually be counterproductive to hospital finances despite the perceived efficiencies created by SDD. This could well exacerbate the already existing inequities in access to TAVR faced by rural, minority, and socioeconomically disadvantaged populations.…”