P4263Outcomes in a resource-constrained economy: results from the multi-centre South African SHARE-TAVI registry

Abstract

In the dichotomous healthcare economy of South Africa, 84% of the population is uninsured and relies on severely resource-constrained State-provided facilities which focus on primary healthcare and treatment of communicable diseases (AIDS, TB). The private sector accounts for 52% of all national healthcare spend and provides best practice healthcare delivery and technologically advanced care such as TAVIs, to the insured 16%. SHARE-TAVI registry was set up by SA Heart to prospectively study all patients receiving TAVI in South Africa, delineating the unique challenges faced and comparing outcomes to international data. The prospective multicentre registry is designed to capture data for all patients undergoing TAVI at all active TAVI centres across South Africa, in a dedicated web-based database. Results: 11 centres perform TAVI, all capture data into the registry, 9 centres perform less than 20 implants per year. 15% of procedures were in the 3 State teaching facilities. Outcomes reported as defined by the VARC-2 criteria. From Sept 2014 to Feb 2017, a total of 368 patients were entered [this is not the total number of patients considered for TAVI] and 256 of these received implants. Declined funding accounted for most of the 42 patients who did not receive an implant. 70 of the entered patients are suitable for TAVI but are motivating for procedure funding with their medical funder. The median wait for a funding decision to be made is 65.83d (range 0-1095d) & days to procedure is 92d (range 1-1124d) from 1st TAVI evaluation consultation. The mean age was 80.3±7.3 yrs and mean risk prediction values were 5.2%±2.9 [STS PROM]; 21.8±15.2 [logEuroSCORE] and 7.1%±7.4 [EuroSCORE 2], making the population comparable to US Corevalve Pivotal trial population and the German Aortic Valve registry [GARY]. Transfemoral access was used in 90.2% with overall procedural success in 94%. Peri-operative mortality was 4.45% and complications included stroke [0.8%], bleeding [6.6%], and vascular complication [8.2%]. Pacemaker implantation of 5.5% was lower than in comparable registries. Mean ICU stay was 2.36±1.89 days and hospital stay 5.4±1.9 days. 30-day allcause mortality was 11.7% [compared to 3.4% in US Corevalve and 5.6% for GARY] and 1-year mortality was 17.6% [compared to 14.2% in US Corevalve and 20% for GARY]. Non-cardiac mortality of 2.3% mostly resulted from malignancy. The length of ICU stay [State 1.79±1.9 d vs. Private 2.46±1.87 ds] and total admission [State 4.52±3.4d vs. Private 5.16±4.2 d] was shorter in the State sector, with outcomes in both sectors comparable to international figures. Conclusions: In resource-constrained economies, funding remains a major challenge for appropriate use of TAVI. The outcomes for predominantly low volume centres are worse in the short term but comparable to international figures at 1 year, and health care delivery and outcomes in the resource-constrained State sector are comparable to the private sector.