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Original Investigation
June 10, 2020

Geographic Access to Transcatheter Aortic Valve Replacement Centers in the United States: Insights From the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry

Author Affiliations
  • 1Duke Clinical Research Institute, Durham, North Carolina
  • 2Department of Surgery, Duke University Medical Center, Durham, North Carolina
  • 3Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
  • 4Marcus Heart and Vascular Center, Department of Cardiovascular Surgery, Piedmont Heart Institute, Atlanta, Georgia
  • 5University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
  • 6Department of Medicine, Columbia University Irving Medical Center/New York Presbyterian Hospital, and the Cardiovascular Research Foundation, New York, New York
  • 7Associate Editor, JAMA Cardiology
  • 8Division of Cardiology, University of Colorado School of Medicine, Aurora
  • 9Cardiovascular Service Line, Baylor Scott & White Health, Plano, Texas
  • 10Duke-Margolis Center for Health Policy, Durham, North Carolina
JAMA Cardiol. 2020;5(9):1006-1010. doi:10.1001/jamacardio.2020.1725
Key Points

Question  What is the geographic access to transcatheter aortic valve replacement (TAVR) centers in the United States?

Findings  In this observational study, 1 232 568 of 47 527 537 individuals 65 years and older lived in a zip code with a TAVR center, and 43 789 169 (92.1%) lived in a hospital referral region containing a TAVR center. For those who underwent successful TAVR, median driving time to implanting center was 35.0 minutes (interquartile range, 20.0-70.0 minutes).

Meaning  In the context of the US health care system where specialized care is centralized, TAVR services have significant penetration.

Abstract

Importance  Geographic access to transcatheter aortic replacement (TAVR) centers varies in the United States as a result of controlled expansion through minimum volume requirements.

Objective  To describe the current geographic access to TAVR centers in the United States.

Design, Setting, and Participants  Observational study from June 1, 2015, to June 30, 2017. United States census data were used to describe access to TAVR center. Google Maps and the Society of Thoracic Surgeons American College of Cardiology Transcatheter Valve Therapy Registry were used to describe characteristics of patients undergoing successful TAVR according to proximity to implanting center. The study analyzed 47 527 537 individuals 65 years and older in the United States and 31 098 patients who underwent successful transfemoral TAVR, were linked to fee-for-service Medicare, and had a measurable driving time.

Main Outcomes and Measures  Median driving distance to a TAVR center.

Results  Among 40 537 zip codes in the United States, 490 (1.2%) contained a TAVR center, and among 305 hospital referral regions (HRR), 234 (76.7%) contained a TAVR center. Of the 31 749 patients who underwent successful transfemoral TAVR and were linked to fee-for-service Medicare, 31 098 had a measurable driving time. Mean (SD) age was 82.4 (6.9) years, 14 697 patients (47.3%) were women, and 7422 (23.87%) lived in a rural area. This translated to 1 232 568 of 47 527 537 individuals (2.6%) 65 years and older living in a zip code with a TAVR center and 43 789 169 (92.1%) living in an HRR with a TAVR center. Among 31 749 patients who underwent successful transfemoral TAVR and were linked to fee-for-service Medicare, 31 098 had a measurable driving time. All of these patients (100.0%) underwent their procedure in a TAVR center within their HRR, with 1350 (4.3%) undergoing TAVR in a center within their home zip code. Median driving time to implanting TAVR center was 35.0 minutes (IQR, 20.0-70.0 minutes), ranging from 2.0 minutes to 18 hours and 48 minutes.

Conclusions and Relevance  Most US individuals 65 years and older live in an HRR with a TAVR center. Among patients undergoing successful transfemoral TAVR, median driving time to implanting center was 35.0 minutes. Within the context of the US health care system, where certain advanced procedures and specialized care are centralized, TAVR services have significant penetration. More studies are required to evaluate the effect of geographic location of TAVR sites on access to TAVR procedures among individuals with an indication for a TAVR within the US population.

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