OBJECTIVE:To compare mortality, healthcare utilization, and costs between patients with symptomatic and asymptomatic mixed aortic valve disease (MAVD). METHODS:We analyzed Optum United Health Care database for US patients with aortic insufficiency (AI) claims (2017-2024) and prior/concurrent aortic stenosis (AS) claims, requiring 12 months continuous enrollment. Patients with baseline aortic valve replacement (AVR) were excluded. Symptomatic MAVD (SMAVD) was defined as ≥2 baseline visits for heart failure, angina, dyspnea, or syncope. Outcomes included mortality, time to home health/skilled nursing facility (SNF), and annualized healthcare utilization and costs, analyzed using Cox proportional hazard and general linear models. RESULTS:Among 132,361 MAVD patients, 73.62% (n = 97,448) were symptomatic at diagnosis. Of initially asymptomatic patients, 58.94% became symptomatic within 5 years. Only 22% received AVR within 5 years. SMAVD patients had higher mortality (HR 1.48, 95% CI 1.44-1.53), home health utilization (HR 1.32, 95% CI 1.30-1.35), SNF admissions (HR 1.38, 95% CI 1.35-1.41), and $11,120 higher annual costs. CONCLUSIONS:SMAVD patients experience significantly worse outcomes than asymptomatic patients. Early detection and timely interventions are critical to reducing MAVD's healthcare burden.

Background Despite advances in diagnostic capabilities and therapeutic options for aortic stenosis (AS), evidence suggests substantial underdiagnosis and care delays in real-world practice. This study examines patterns and disparities in AS diagnosis following echocardiographic identification, quantifying delays in diagnosis and subsequent care. Methods Using the Optum® Market Clarity Dataset (2016–2023), we identified patients with first echocardiographic evidence of moderate or severe AS. Time-to-event analyses examined delays between echocardiographic findings and formal diagnosis (defined by ICD code assignment), subsequent imaging, and interventions. Analyses were stratified by severity, demographics, and care setting. Results Among 2366 moderate and 1327 severe AS patients, 22.0% and 38.3% received formal diagnoses within one year of echocardiogram, respectively. Cumulative incidence of AS diagnosis at one year was lower in women vs men (moderate: 17.3% vs 27.8%; severe: 33.8% vs 43.0%) and non-White vs White patients (moderate: 11.4% vs 24.6%; severe: 25.8% vs 40.4%; all P ≤ 0.0001). Formal diagnosis was associated with increased likelihood of subsequent care (composite of follow-up imaging or aortic valve replacement) (moderate AS: HR 1.68, P < 0.0001; severe AS: HR 2.25, P < 0.0001). Conclusions This analysis reveals substantial delays in formal ICD-coded AS diagnosis following its echocardiographic detection, with concerning disparities across demographic groups. These findings suggest gaps between clinical recognition and formal documentation of AS, with implications for care continuum. Clinical perspectives What Is New?•Using a large, real-world integrated claims and EMR database, this study demonstrates that fewer than one-quarter of patients with echocardiographically confirmed moderate AS and fewer than 40% with severe AS receive a formal ICD-coded diagnosis within one year, with substantially lower rates among women and non-White patients.What Are the Clinical Implications?•These findings reveal a critical gap between echocardiographic detection of AS and formal clinical documentation, suggesting that administrative claims data alone may substantially underestimate the true burden of AS in the population.•Formal AS diagnosis was independently associated with a significantly higher likelihood of receiving subsequent care — including surveillance imaging and aortic valve replacement — underscoring that closing the documentation gap may be a meaningful lever for improving outcomes and reducing disparities in AS management.

OBJECTIVES:To examine the determinants of unmet transcatheter aortic valve replacement (TAVR) needs and their impact on patient survival among Medicare beneficiaries with aortic stenosis. METHODS:We developed a county-level mismatch score measuring the gap between actual TAVR procedures performed and expected need based on population differences. Counties were classified as metropolitan, semiurban, or rural. Factors associated with larger mismatches were identified, and mortality rates among aortic stenosis (AS) patients were examined in relation to mismatch scores. We analyzed Medicare data from 2016 to 2022 across 3129 US counties. The mismatch score was developed to account for population differences and county urbanicity classification. Statistical analyses identified factors associated with TAVR mismatch and its relationship to mortality outcomes. RESULTS:We found substantial geographic variation in TAVR delivery. Counties with higher TAVR mismatch scores showed associations with fewer TAVR-providing hospitals, less market concentration, higher AS prevalence, and lower household incomes. Counties with greater gaps between needed and actual TAVR procedures were also associated with higher mortality rates. This relationship between mismatch and mortality was particularly strong in semiurban counties. CONCLUSIONS:Our findings identify associations between TAVR access gaps and patient outcomes, as well as factors linked to these access patterns. Counties with higher TAVR mismatch scores showed correlations with healthcare capacity constraints, geographic location, and socioeconomic factors. These associations suggest that mismatches may be addressed through targeted approaches based on local needs to improve care delivery for patients with AS in regions currently experiencing access challenges.

To analyze and compare the differences in mortality, healthcare utilization, and costs between patients with symptomatic and asymptomatic isolated aortic insufficiency (AI). We utilized Optum United Health Care Database for US patients who had an AI claim between 2017 and 2022, with 12 months of continuous enrollment (baseline period) prior to diagnosis. Exclusion criteria were AVR during the baseline period or a diagnosis of aortic stenosis. Patients were split into two cohorts: those with symptoms (SAI) and those without (AAI). SAI patients had ≥ 2 visits for heart failure, angina, dyspnea, or syncope at baseline. Outcomes of interest were all-cause mortality, time to home health, time to SNF, annualized healthcare utilization, and annualized costs. We used the Cox proportional model to estimate mortality and general linear models to estimate healthcare utilization and costs. Outcomes were modeled separately. Of 249,660 patients, 58.23% were symptomatic; they were generally older and sicker than the AAI cohort, and less than 1% received AVR. Almost half of AAI patients were estimated to develop symptoms within 5 years post-diagnosis. SAI outcomes were consistently higher across all measured outcomes. SAI patients have higher mortality, healthcare utilization, and costs than AAI. However, AI can progress quickly from asymptomatic to symptomatic. Early detection and timely interventions to slow the progression or address it surgically should be emphasized to limit the impact of AI.

BACKGROUND:While approximately 17% of patients less than 80 years old require coronary access in the 7 years following their TAVR, the need for coronary access among older TAVR patients is unknown. METHODS:We examined the percentage of Medicare beneficiaries aged 80-90 years that require coronary access [percutaneous coronary intervention (PCI) or angiogram] in the 8 years following their TAVR using data from the Medicare 5% Standard Analytic File (2011-2021). The need for coronary access in older patients was estimated for all TAVRs, TAVR patients with and without a history of PCI, and TAVR patients with and without coronary artery disease (CAD) using time-to-event models adjusted for age, sex, race, region, ECI score, concomitant CABG, CAD, PCI, and current or recent smoker status. Multivariate log-gamma regressions were used to estimate the total cost of hospitalizations requiring coronary access post-TAVR. RESULTS:A total of 6845 patients met inclusion criteria. The incidence rates for undergoing PCI or angiogram at 1, 3, 5, and 8 years were 1.9%, 4.0%, 5.5%, and 6.3%, respectively. TAVR patients with PCI demonstrated higher rates of coronary intervention compared to those without PCI (10.2% vs. 6.2% at 8 years, respectively). Similarly, TAVR patients with a prior CAD diagnosis exhibited increased rates of coronary intervention compared to those without a prior CAD diagnosis (7.4% vs. 2.1% at 8 years, respectively). The mean adjusted cost of hospitalizations requiring coronary access was $30,170 [95% Confidence Interval: $27,865-$32,665]. CONCLUSIONS:Approximately 6.8% of older TAVR patients require coronary access in the 8 years following their index procedure. The presence of a prior PCI or CAD diagnosis is associated with an increased requirement for subsequent coronary access.

This study investigates the impact of geographic and socioeconomic barriers on access to transcatheter aortic valve replacement (TAVR). Utilizing Medicare data from the US Centers for Medicare and Medicaid Services, this study analyzed TAVR and surgical aortic valve replacement (SAVR) procedures among beneficiaries from 2017 to 2022. Geographic units were defined by 5-digit zip codes, categorized on the basis of TAVR/SAVR volume into four categories: (1) no TAVR or SAVR, (2) no-TAVR zone (SAVR present, no TAVR), (3) low-TAVR zone (TAVR/SAVR ratio ≤ 0.5), and (4) TAVR accessible (TAVR/SAVR ratio > 0.5). The differential distance index (DDI) was developed to measure travel hurdles, calculated as the difference in miles from a patient’s zip code center to the treatment hospital (TAVR versus SAVR, CABG (coronary artery bypass grafting), and PCI (percutaneous coronary intervention) comparators). This study maintained a continuous access variable to model outcomes such as the ratio or volume of TAVR/SAVR and the percentage share of TAVR/AVR within each zip code over biennial periods (2017–2018, 2019–2020, 2021–2022). Covariates in the model included population density, area deprivation index (ADI), and calendar time, with an exploration of the interaction between DDI and ADI. The analysis revealed significant geographic disparities in TAVR access across the USA, with no-TAVR zone and low-TAVR zone areas often featuring lower population densities, higher ADIs, and more rural settings. Increased travel distance (DDI) significantly correlated with lower TAVR utilization, emphasizing distance as a critical barrier. Furthermore, both ADI and DDI emerged as significant predictors of TAVR volume and share, underlining the compound effect of socioeconomic status and geographic distance on healthcare access. This study highlights the critical role of geographic and socioeconomic barriers in accessing advanced medical treatments like TAVR. Addressing these barriers may ensure equitable healthcare distribution, guiding policymakers and providers towards more accessible healthcare solutions for all populations.

BACKGROUND:Prior studies have demonstrated that peri-procedural complications are associated with increased healthcare costs after surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR). Given the technological and procedural advances that have occurred in the management of aortic valve disease over the last decade, this study aims to understand the incremental cost of specific complications after SAVR and TAVR in contemporary practice. METHODS:Using the Medicare 100% standard analytic file, we identified all beneficiaries receiving SAVR or TAVR in the United States during fiscal year 2021. Specific complications were identified via ICD-10 codes. Multivariable analyses were performed to estimate the incremental cost and length of stay (LOS) for each complication. Attributable costs were calculated by adjusting the incremental cost of each complication for its incidence. RESULTS:The cost of an uncomplicated TAVR index hospitalization was $46,257 with LOS 2.2 days, while an uncomplicated SAVR cost $58,488 with LOS 8.1 days. The presence of any complication increased costs and LOS for TAVR ($66,601; 5.9 days) and SAVR ($88,900; 13.4 days). Prolonged ventilation was associated with the highest incremental cost for TAVR ($55,742), while pacemaker implantation had the highest attributable cost ($1,270). Prolonged ventilation accounted for the highest incremental ($69,728) and attributable ($2,580) cost associated with SAVR. CONCLUSION:This study provides contemporary data on the incremental costs of specific peri-procedural complications associated with TAVR and SAVR. These findings can be used to develop targeted interventions to optimize healthcare resource utilization in patients undergoing aortic valve replacement.

Background:Patients with severe tricuspid regurgitation (TR) are at risk for significant morbidity and mortality. Data on long-term clinical outcomes and health care resource utilization for this population are limited. Methods:We used the Optum Market Clarity database from 2016 to 2022 to identify patients with severe TR based on a combination of physician documentation, claims for severe TR, and echocardiography within 3 months of the diagnosis. Event rates through 3-year follow-up were calculated using Kaplan-Meier methodology, and health care resource use and expenditures were calculated using the Bang and Tsiatis censoring method. Secondary analyses were performed among patients with severe, symptomatic TR, which required additional physician documentation of prespecified signs or symptoms. Results:We identified 1190 patients with severe TR and no previous tricuspid valve surgery between 2016 and 2022. The mean age was 72 years, and 67% were female. Baseline comorbidities were common, with a mean Elixhauser score of 9.4 ± 4.0 (range, 0-31). Of patients with detailed echocardiographic data available (N = 322), 46% had normal left ventricular ejection fraction. Three-year rates of all-cause mortality, stroke, and any tricuspid valve surgery were 47.9, 19.1, and 7.5%, respectively. Health care-related resource utilization was high, with cumulative 3-year costs of approximately $127,000/patient. Conclusions:Over 3 years of follow-up, patients with severe TR had high rates of death and adverse clinical events and incurred substantial health care costs. Longer-term data regarding the impact of transcatheter interventions for severe TR on clinical outcomes and costs are needed to better understand the value of these novel therapies.

Background To explore how differences in local socioeconomic deprivation impact access to aortic valve procedures and the treatment of aortic valve disease, in comparison to other open and minimally invasive surgical procedures. Methods and Results Procedure volume data were obtained from the Healthcare Cost and Utilization Project from 18 states from 2016 to 2019 and merged with area deprivation index data, an index of zip code‐level socioeconomic distress. We estimate the relationship between local deprivation ranking and differences in volumes of aortic valve replacement, which include transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR), versus coronary artery bypass graft surgery and laparoscopic colectomy (LC). All regressions control for state and year fixed effects and an array of zip code‐level characteristics. TAVR procedures have increased over time across all zip codes. The rate of increase is negatively correlated with deprivation ranking, regardless of the higher share of hospitalizations per population in high deprivation areas. Distributional analysis further supports these findings, showing that lower area deprivation index areas account for a disproportionately large share of SAVR, TAVR, and LC procedures in our sample relative to their share of all hospitalizations in our sample. By comparison, the cumulative distribution of coronary artery bypass graft procedures was nearly identical to that of total hospitalizations, suggesting that this procedure is equitably distributed. Regressions show high area deprivation index areas have lower prevalence of SAVR ( β =−15.1%, [95% CI, −26.8 to −3.5]), TAVR ( β =−9.1%, [95% CI, −18.0 to −0.2]), and LC ( β =−19.9%, [95% CI, −35.4 to −4.4]), with no statistical difference in the prevalence of coronary artery bypass graft ( β =−2.5%, [95% CI, −12.7 to 7.6]), a widespread and commonly performed procedure. In the population aged ≥80 years, results show high area deprivation index areas have a lower prevalence of TAVR ( β =−11.9%, [95% CI, −18.7 to −5.2]) but not SAVR ( β =−0.8%, [95% CI, 8.1 to 6.3]), LC ( β =−3.5%, [95% CI, −13.4 to −6.4]), or coronary artery bypass graft ( β =5.2%, [95% CI, −1.1 to 1.1]). Conclusions People living in high deprivation areas have less access to life‐saving technologies, such as SAVR, and even moreso to device‐intensive minimally invasive procedures such as TAVR and LC.

Geographic disparities in access to inpatient procedures are a significant issue within the US healthcare system. This study introduces the Procedure Access Inequality (PAI) index, a standardized metric to quantify these disparities while adjusting for disease prevalence. Using data from the Healthcare Cost and Utilization Project State Inpatient Databases, we analyzed inpatient procedure data from 18 states between 2016 and 2019. The PAI index reveals notable variability in access inequality across different procedures, with minimally invasive and newer procedures exhibiting higher inequality. Key findings indicate that procedures such as skin grafts and minimally invasive gastrectomy have the highest PAI scores, while cesarean sections and percutaneous coronary interventions have the lowest. The study highlights that higher inequality is associated with greater market concentration and in particular, fewer hospitals offering these procedures. These findings emphasize the need for targeted policy interventions to address procedural access disparities to promote more equitable healthcare delivery across the United States.

BackgroundAortic stenosis (AS) is a prevalent valvular disorder necessitating timely intervention, particularly when symptomatic. Aortic valve replacement (AVR) is the recommended treatment, but delays in access to AVR are common and linked to adverse outcomes and increased health care costs. This study aims to assess the health care cost burden associated with delaying transcatheter AVR (TAVR) in Medicare Advantage beneficiaries with clinically significant AS.Methods and ResultsThis retrospective database study utilized the Optum de-identified U.S. claims database, encompassing Medicare Advantage enrollees. Patients aged 65 years or older were identified as having AS based on medical billing codes and were required to have a record of syncope, dyspnea, fatigue, chest pain/angina, or heart failure prior to, on or within 30 days of their incident AS diagnosis. Total health care costs were analyzed over a 2-year period, regressed against the delay in receiving TAVR, and adjusted for covariates. In the 4105 patients meeting study inclusion criteria, delays in TAVR were associated with a significant increase in health care costs, translating to those waiting 12 months for TAVR incurring an additional cost of $10,080 compared to those receiving TAVR promptly. Non-TAVR related costs largely drove this increase.ConclusionsDelaying TAVR in clinically significant AS patients is associated with higher health care costs, emphasizing the need for timely interventions. Addressing delays in TAVR access and optimizing pre-TAVR workup can potentially improve patient outcomes and reduce health care expenditure.

Background The treatment of severe aortic stenosis has evolved considerably since the introduction of transcatheter aortic valve replacement (TAVR), yet trends in complications for patients undergoing TAVR or surgical aortic valve replacement (SAVR) at a national level have yet to be evaluated. Methods and Results We performed a retrospective cohort study using Medicare data to evaluate temporal trends in complications among beneficiaries, aged ≥65 years, treated with elective isolated transfemoral TAVR or SAVR between 2012 and 2019. The study end point was the occurrence of a major complication (composite outcome) during index and up to 30 days after. Multivariable logistic regression was used to assess odds of complications for TAVR and SAVR, individually over time, and for TAVR versus SAVR, over time. The cohort included 211 212 patients (mean±SD age, 78.6±7.3 years; 45.0% women). Complication rates during index following elective isolated aortic valve replacement decreased from 49% in 2012 to 22% in 2019. These reductions were more pronounced for TAVR (41% to >19%, Δ=22%) than SAVR (51% to >47%, Δ=4%). After risk adjustment, the risk of any complication with TAVR was 47% ( P <0.0001) lower compared with SAVR in 2012, and 78% ( P <0.0001) lower in 2019. TAVR was independently associated with reduced odds of complications each year compared with 2012, with the magnitude of benefit increasing over time (2013 versus 2012: odds ratio [OR], 0.89 [95% CI, 0.81–0.97]; 2019 versus 2012: OR, 0.35 [95% CI, 0.33–0.38]). These findings are consistent for complications up to 30 days from index. Conclusions Between 2012 and 2019, the risk of complications after aortic valve replacement among Medicare beneficiaries decreased significantly, with larger absolute and relative changes among patients treated with TAVR than SAVR.

Background:Opportunities to minimize inequities in accessing treatments for tricuspid regurgitation disease should be considered. Objective:The objective of this study was to explore how access to new tricuspid regurgitation technologies change when heart centers are restricted by payer coverage requirements. Methods:This case series study identified U.S. hospitals with a record of performing transcatheter aortic valve replacement, transcatheter edge-to-edge repair, and tricuspid and mitral valve procedures for the calendar year 2021. Population 65+ years of age and Area Deprivation Index (ADI), were identified by zip code. We created 10 scenarios based on low, medium, and high hospital volumes for combinations of transcatheter aortic valve replacement, transcatheter edge-to-edge repair, tricuspid and mitral valve procedures. Distance from a zip code to scenario eligible hospitals was determined; the closest hospital to a zip code was identified as the distance someone with tricuspid regurgitation would have to travel for care. Each scenario was modeled with the dependent variable as the distance to the nearest scenario eligible hospital by ADI, controlling for population size 65+ years of age. Results:A total of 929 U.S. hospitals met our study inclusion. ADI was statistically significant in every scenario-when ADI goes up (more deprivation), distance to the nearest hospital increases. Patients in zip codes with low ADI travel an average of 15 to 52 miles, medium ADI 31 to 67 miles, and high ADI 47 to 95 miles. Conclusions:Patients in higher socioeconomic deprivation areas travel longer distances to hospitals meeting procedure volume requirements. Policymakers and patient advocacy groups should consider this to ensure equitable access to potentially life-saving technologies.

Background Aortic regurgitation is distinguished by the backflow of blood from the aorta into the left ventricle. American College of Cardiology/American Heart Association guidelines recommend surgical aortic valve replacement (SAVR) for patients with symptomatic aortic regurgitation (sAR). This study estimates the difference in mortality, health care use, and costs between patients with sAR who receive SAVR within 12 months of diagnosis versus those who do not. Methods and Results We used the Optum United Healthcare database to identify 132 317 patients diagnosed with sAR from 2016 to 2021 who had at least 6 months of enrollment before sAR and 12 months of enrollment after. Criteria were no history of aortic stenosis or transcatheter aortic valve replacement and ≥2 visits for heart failure, angina, dyspnea, or syncope. Outcomes were all‐cause mortality, health care use, and annualized cost. Baseline differences in demographics and comorbidities were adjusted with inverse propensity score weighting. We modeled survival and estimated health care use and costs using Cox proportional hazards and general linear models, respectively. Of the 132 317 patients, 400 underwent SAVR within 12 months of diagnosis. They were on average younger, more often men, and with a slightly higher Elixhauser Comorbidity Index score. After inverse propensity score weighting, patients with sAR who had SAVR had lower mortality, fewer inpatient and emergency department visits, fewer hospital days, and lower annualized cost. Conclusions SAVR performed within 12 months of an sAR diagnosis is associated with improved mortality and lower annualized health care use and costs. These clinical and economic benefits should be considered when managing patients with sAR.

INTRODUCTION:Chronic axial low back pain (CLBP) that is not responsive to medication management or physical therapy often requires significant clinical intervention. Several interventional pain management options exist, including a 60-day peripheral nerve stimulation (PNS) treatment. This economic evaluation investigated the potential for projected cost savings associated with prioritizing 60-day PNS treatment relative to a 'standard of care' (SOC) approach (where patients do not have access to 60-day PNS). METHODS:A decision tree (supervised machine learning) model tracked treatment progression across two hypothetical cohorts of US patients with CLBP in whom non-interventional options were ineffective (Cohort A: treatment starting with 60-day PNS followed by any additional interventional and surgical treatments versus Cohort B: standard of care interventional and surgical treatments without access to 60-day PNS). Treatment efficacy estimates were based on published success rates. Conditional on treatment failure, up to two additional interventions were considered within the 12-month time frame in both cohorts. SOC treatment options included epidural injection, radiofrequency ablation (RFA), basivertebral nerve ablation (BVNA), PNS permanent implant (PNS-PI), spinal cord stimulator (SCS) trial/implant, and spinal fusion surgery. Treatment choice probabilities in both cohort algorithms were based on clinician interviews. Costs were based on national Medicare reimbursement levels in the ambulatory surgery center (ASC) setting. Savings reflected the difference in projected costs between cohorts. A Monte Carlo simulation and sensitivity analyses were conducted to generate confidence intervals and identify important inputs. RESULTS:The treatment algorithm which prioritized initial 60-day PNS treatment was projected to save $8056 (95% CI $6112-$9981) per patient during the first year of interventional treatment relative to the SOC approach. CONCLUSIONS:Use of the 60-day PNS treatment as an initial interventional treatment in patients with CLBP may result in significant savings for Medicare. Projected savings may be even larger for commercial payers covering non-Medicare patients.