Center variability in medicare claims– based publicly reported transcatheter aortic valve replacement outcome measures

Abstract

BACKGROUND: Public reporting of transcatheter aortic valve replacement (TAVR) claims– based outcome measures is used to identify high-and low-performing centers. Whether claims-based TAVR outcomes can reliably be used for center-level comparisons is unknown. In this study, we sought to evaluate center variability in claims-based TAVR outcomes used in public reporting. METHODS AND RESULTS: The study sample included 119 554 Medicare beneficiaries undergoing TAVR between January 2014 and October 2018 based on procedure codes in 100% Medicare inpatient claims. Multivariable hierarchical logistic regression was used to estimate center-specific adjusted rates and reliability (R) of 30-day mortality, discharge not to home/self-care, 30-day stroke, and 30-day readmission. Reliability was defined as the ratio of between-hospital variation to the sum of the between-and within-hospital variation. The median (interquartile range [IQR]) center-level adjusted outcome rates were 3.1% (2.9%– 3.4%) for 30-day mortality, 41.4% (31.3%– 53.4%) for discharge not to home, 2.5% (2.3%– 2.7%) for 30-day stroke, and 14.9% (14.4%–15.5%) for 30-day readmission. Median reliability was highest for the discharge not to home measure (R=0.95; IQR, 0.94– 0.97), followed by the 30-day stroke (R=0.92; IQR, 0.87– 0.94), 30-day mortality (R=0.86; IQR, 0.81– 0.91), and 30-day readmission measures (R=0.42; IQR, 0.35– 0.51). Across outcomes, there was an inverse relationship between center volume and measure reliability. CONCLUSIONS: Claims-based TAVR outcome measures for mortality, discharge not to home, and stroke were reliable measures for center-level comparisons, but readmission measures were unreliable. Stakeholders should consider these findings when evaluating claims-based measures to compare center-level TAVR performance.