New study highlights inequity in access to TAVR procedure across Canada

Transcatheter aortic valve replacement (TAVR) is a revolutionary technology for the treatment of patients with severe calcific aortic stenosis. Demand for TAVR has grown tremendously across Canada, but there are significant differences in capacity and wait-times across the country with some patients waiting up to 60 percent longer for the procedure, report investigators in the Canadian Journal of Cardiology, published by Elsevier.

Aortic stenosis restricts the blood flow from the left ventricle to the aorta, reducing blood flow to the rest of the body, and may also affect the pressure in the left atrium. TAVR has emerged as the treatment of choice for elderly patients suffering from severe aortic stenosis. A minimally invasive surgical procedure, it repairs the valve without removing the old, damaged valve. Instead, the procedure "wedges" a replacement valve into the aortic valve's place via a catheter inserted through a blood vessel in the leg or chest. Importantly, it can be performed in patients with medical conditions that make them unfit for full open heart surgery.

In the past, such patients needed open heart surgery for surgical aortic valve replacement or would be untreated. TAVR is a transformative treatment. There has been an exponential growth in demand in Canada. However, in some provinces there has not been a corresponding growth in capacity."

Harindra C. Wijeysundera, MD, Ph.D., Schulich Heart Centre, Divisions of Cardiology and Cardiac Surgery, Sunnybrook Health Sciences Centre, University of Toronto; Institute for Clinical Evaluative Sciences (ICES); and Institute for Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada

Investigators looked at the increase in the number of procedures across Canada and determined whether there are differences in access based on wait-times depending on geographic location. TAVR procedures are currently performed by 29 TAVR programs, which involve 31 hospitals across nine of the 12 Canadian provinces and territories. Researchers identified nearly 5,000 TAVR procedures that took place from April 1, 2014 to March 31, 2017 across these nine provinces. Wait-time was defined as the number of days from the initial referral for the TAVR procedure. They found that despite a year-over-year increase in overall capacity, there was a greater than three-fold difference in capacity among provinces.

They also noted a marked variation in wait-times across Canada, for example, from 71.5 days in Newfoundland to 190.5 and 203 days in Manitoba and Alberta, respectively. On average, the same patient could potentially wait up to sixty percent longer in some provinces compared to others.

"The current study is very concerning in that there are long waits for TAVR and that these are markedly different across the country. Being on the waiting list for TAVR for long periods is associated with increased risk of death and hospitalization," noted Dr. Wijeysundera. "Such inequity is a call for policy makers across Canada to re-evaluate provincial funding mechanisms for this therapy to ensure that every Canadian has access to the standard of care for aortic stenosis in a timely fashion."

In an accompanying editorial, Janarthanan Sathananthan, MBChB, MPH, and Kenneth Gin, MD, both of the Centre for Heart Valve Innovation, St. Paul's Hospital, University of British Columbia; Centre for Cardiovascular Innovation, University of British Columbia; and Vancouver General Hospital, Vancouver Coastal Health, Vancouver, BC, Canada, noted that in Canada, TAVR is currently offered predominantly to patients of high and intermediate surgical risk. "As TAVR expands to low risk patients with increasing demand on TAVR services, these inequalities may continue to worsen and may result in poor outcomes," added Dr. Sathananthan.

The ability to increase patient capacity and reduce waiting time does not necessarily require an increase in resources wrote Dr. Sathananthan and Dr. Gin, observing that in some situations, inequalities can be reduced by improving processes of care. Two recently reported studies have demonstrated that by optimizing and delivering consistent care before, during, and after the procedure, patients can achieve a high rate of safe next-day discharge, which has the potential to increase both access to care and patient volume, while using current resources.

"While achieving consistent, reproducible care is desirable at a center level, there is a need for national guidelines for TAVR care across Canada," commented Dr. Gin. "Improving access to healthcare for TAVR patients will require both provincial and national coordination. This is of importance as TAVR increasingly becomes an accepted alternative to surgical aortic valve replacement for patients with severe calcific aortic stenosis."