As the Centers for Medicare and Medicaid Services considers expanding transcatheter aortic valve replacement, a minimally invasive heart surgery, a study in the New England Journal of Medicine authored by the Baylor Scott and White Plano Heart Hospital’s Dr. Michael Mack shows that results improve as TAVR centers increase surgery volume.
TAVR involves inserting a collapsed valve through an artery near the hip and expanding it once it is in place in the aorta, and is becoming more common because of its reduced recovery time and risk compared to open heart surgery. The surgery was first used for older, more fragile patients who couldn’t handle an open heart surgery, but is being considered for younger patients. As TAVR has grown, it has become a multi-billion dollar industry, and because patients are often elderly (Mick Jagger had the procedure done) and on Medicare, CMS is trying to figure out the standards for quality and frequency.
Baylor Scott and White is the fourth largest provider of TAVR surgeries and the largest in the state. While the surgery reduces recovery time and is just as safe as open heart surgery, it is nearly six times as expensive as open heart surgery at $32,000, though with the reduced hospital stay, total costs are often close to what they would be with traditional surgery.
The valve lasts 8-10 years, but because most of the patients are elderly and die prior to needing a new valve, it is difficult to know the exact lifetime of the valve, which is made from animal tissue. The study discusses lowering the patient age from 81-84 to the low 70s, but like any skill, the more one does the better they are. If CMS expands coverage to reimburse for TAVR for younger patients, more medical centers will need to become experts in the surgery.
“Not everybody can come to Baylor Plano or Cleveland clinic,” says Mack. “Can you be cared for in your local community with the same results?”
Looking ahead, Mack sees the same process expanding to other valves and running through other arteries or veins, as well as solving the problem of what to do what people are frequently outliving their replacement valve.
There are currently 600 programs in the country that do TAVR, and expansion has its own risks as less-experienced surgeons undertake the procedure. CMS is considering upping the number of hospitals to 800. “If you are going to expand, do it cautiously,” Mack says.