What are the differences in hospital and patient characteristics of mitral repair or replacement (MVRR) in the United States as a function of hospital procedure volume?
Patient demographics and geography of centers performing 25 or more MVRRs per year or 40 or more MVRRs per year differed in race/ethnicity, rurality, and insurance status from those performing fewer cases. Centers performing 25 or more and 40 or more MVRRs per year were located in 77.3% and 55.3% of geographic hospital referral regions, respectively, and regional access exists for 92% and 82% of the US population, respectively.
Ninety-two percent and 82% of the US population lives in a hospital referral region with a center performing 25 or more or 40 or more MVRRs per year, respectively; disparities in patients and geography exist between these centers and those performing fewer MVRRs.
Volume metrics may have relevance in the evaluation of valve center expertise. However, a paucity of data exists regarding the quantity, volume, and geographic location of mitral valve (MV) surgical centers in the United States and the proportion of underserved populations they treat.
To evaluate the hospital, patient, and procedural characteristics of mitral valve repair or replacement (MVRR) in the United States as a function of hospital procedure volume.
Design, Setting, and Participants
This cross-sectional, multicenter observational study was conducted from July 2014 to June 2018. Patients in the Society of Thoracic Surgeons Adult Cardiac Surgery Database undergoing any surgical procedure involving MVRR in the United States were included.
Main Outcomes and Measures
Volume distribution of MVRR by hospital and hospital referral region.
There were 165 405 MVRRs performed in 1082 centers during the study period, of which 86 488 (52.3%) were MV repairs. There were 575 centers (53.1%) that performed 25 or more MVRRs per year. The geographic distribution of centers performing 25 or more MVRRs per year differed from those performing fewer than 25 MVRRs per year. Of 304 designated hospital referral regions, 235 (77.3%) had at least 1 center performing 25 or more MVRRs per year, representing accessibility to 1 or more such centers for 296.4 million of 320.1 million US residents (92.6% of the US population; Midwest, 60.0 million of 68.0 million [88.4%]; South, 112.6 million of 122.6 million [91.9%]; West, 68.6 million of 72.9 million [94.1%]; and Northeast, 54.9 million of 56.6 million [97.1%]). Of 304 hospital referral regions, 168 (55.3%) had at least 1 center performing 40 or more MVRRs per year, representing accessibility to 1 or more such centers for 259.8 million of 317.90 million (81.7%) of the US population (Midwest, 50.5 million of 67.9 million [74.5%]; South, 94.5 million of 121.1 million [78.1%]; West, 64.0 million of 72.8 million [88.0%]; Northeast, 50.1 million of 56.3 million [90.2%]). More black and Hispanic patients received operations in centers performing 25 or more MVRRs per year (22 984) vs those performing fewer than 25 MVRRs per year (3227), yet the proportion was higher in lower-volume centers (22 984 of 148 385 [15.5%] vs 3227 of 17 020 [19.0%]; P < .001). In centers performing 25 or more MVRRs per year vs fewer than 25 MVRRs per year, there was a lower percentage of Medicare and Medicaid patients (47 920 of 148 385 [32.3%] vs 6183 of 17 020 [.3%]; P < .001) and patients from rural zip codes (21 208 of 148 385 [14.3%] vs 3146 of 17 020 [18.5%]; P < .001).
Conclusions and Relevance
Fifty-three percent of all centers performed 25 or more MVRRs per year, and 92.6% of the US population lived in an hospital referral region with at least 1 such center. Disparities in race/ethnicity, rurality, and insurance status exist among patients being treated at centers with different volumes. These data indicate that efforts to centralize care based on volume metrics will need to balance access vs quality.
Vemulapalli S, Grau-Sepulveda M, Habib R, Thourani V, Bavaria J, Badhwar V. Patient and Hospital Characteristics of Mitral Valve Surgery in the United States. JAMA Cardiol. Published online October 02, 2019. doi:10.1001/jamacardio.2019.3659
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