Cardiovascular Rounds

What can you learn from FY 2013 TAVR data?

New benchmarks from the Cardiovascular Roundtable

by Megan Tooley

It’s safe to say it’s been a busy summer for transcatheter aortic valve replacement (TAVR). In the past few months, we’ve seen a number of significant updates related to the procedure, including:

  • CMS proposed new TAVR-specific MS-DRGs in its FY 2015 Inpatient Proposed Rule, which would likely lead to an overall bump in reimbursement for the procedure if approved in August
  • Indications for Medtronic’s CoreValve device were expanded to include TAVR in high-risk patients in June, following initial approval of the device in Jan. 2014 for extreme-risk (i.e., inoperable) patients
  • Edwards Lifesciences’ next-generation Sapien XT device was approved for use in high-risk and inoperable patients just days later

So it seemed a fitting time to provide an update to the benchmarks we shared last year on TAVR cases performed across the United States. We analyzed TAVR claims from the latest Medicare Provider Analysis and Review (MEDPAR) data set, which includes all Medicare cases performed in Fiscal Year (FY) 2013 (from Oct. 1, 2012–Sept. 31, 2013).

Read on for the latest benchmarks on TAVR volumes, patient characteristics, efficiency, and reimbursement, and to get a sense for how these changed in the first two years following FDA approval.

Volumes—and sites—increasing rapidly

National TAVR volumes nearly doubled in 2013 from the previous year, with 10,599 total Medicare cases in FY 2013 as compared to 5,400 claims in 2012. Driving this increase is likely the combination of expanding indications and devices, increased adoption at sites across the country, and better identification of appropriate patients as widespread knowledge and experience with the procedure increases.

(Please note: From this point forward, the analyses presented in this blog reflect traditional Medicare cases, thus excluding Medicare Advantage claims).

As expected, the number of sites performing TAVR in FY 2013 also increased significantly from the year before, as more sites were approved to use the device: 336 sites, up from 228 in FY 2012.

This was accompanied by an increase in volumes per site: the median program volume was 23 TAVR cases, compared to 10 in 2012.

Age distribution remains relatively consistent

As can be expected, the age distribution for TAVR skews toward older patients, with the majority of cases performed in patients over 80—this distribution nearly mimics what was observed in 2012. That said, it will be interesting to see if a downward trend in age will be observed if and when future indications expand to include intermediate-risk patients.

More cases coded “without cath”

TAVR cases were most commonly assigned to MS-DRGs 219 and 220 (valve surgery without cath, but with either a major complication or comorbidity [MCC] or less serious complication or comorbidity [CC] respectively), just as in 2012. However, overall, more cases were performed “without cath” compared to the previous year: 68% of transfemoral and 75% of transapical cases in 2013, compared to 56% of transfemoral and 61% of transapical cases in 2012. One hypothesis for this could be that, as operator experience has increased, there have been less complications requiring a cath to be inserted during the procedure.

(For further context, a TAVR procedure qualifies as “with cath” in two scenarios: a) the cardiac cath screening is performed within three days of the TAVR admission date; b) during the TAVR procedure itself there is a documentable change in patient status that requires a separate cath.)

If CMS’s Inpatient Proposed Rule’s recommendation for new TAVR-specific MS-DRGs is approved in August, this scenario will be completely different in FY 2015, as TAVR cases would be de-coupled from the above MS-DRGs for surgical aortic valve replacement and receive their own codes (and associated reimbursement):

  • MS-DRG 266: Endovascular Cardiac Replacement with MCC (FY 2015 proposed base rate: $51,329)
  • MS-DRG 267: Endovascular Cardiac Replacement without MCC (FY 2015 proposed base rate: $39,175)

No great gains in LOS

Length of stay for TAVR changed little in 2013. LOS for the 25th, 50th, and 75th percentiles were the same across all transfemoral cases in 2013 versus 2012 (4, 6, and 9 days, respectively). LOS for transapical cases made a modest improvement at the 75th percentile—decreasing from 14 days to 11 days between the two years—but, at the 25th and 50th percentile, also remained consistent.

On the one hand, this is not terribly surprising, given the relatively recent approval of TAVR, and that many new programs that began performing TAVR in 2013 were not already involved in the clinical trials (as compared to the cohort the previous year). But as more cases are performed in high-risk, surgery-eligible patients, and operator experience continues to increase, we expect to see some reductions going forward.

Learn how to reduce TAVR LOS with these ten steps

We assembled ten steps to decrease length of stay in TAVR cases.

Check out steps such as using “non-traditional” criteria in patient evaluations, extubating patients while in the OR, and modifying ICU staff expectations of recovery times.

SEE THE 10-POINT PLAN

So, what about reimbursement?

TAVR reimbursement actually decreased slightly between 2012 and 2013: median reimbursement for transfemoral and transapical cases was $48,012 and $50,475, respectively in FY 2013, compared to $50,096 and $57,063 in 2012. In part, this is due to the increase in procedures coded in the lower-paying MS-DRGs 219-221 (“without cath”) as mentioned above.

A number of claims included outlier payment—in fact, more than the previous year. Outlier payments showed up on 24% of transfemoral claims (compared to 21% in 2012) and 32% of transapical claims (compared to 14% in 2012). Median outlier amounts were $7,317 and $8,882 for transfemoral and transapical, respectively.

Evaluating patient outcomes, discharge destination

In-hospital survival rate was 96% for transfemoral and 94% for transapical – up a percentage point each from 2012. Not surprisingly, transfemoral patients were less likely to require intensive post-discharge support than transapical patients—as patients receiving this approach are often more complex, and the procedure itself may require more intensive recovery. For example, only 23% of transfemoral cases were discharged to a skilled nursing facility, compared to 32% of transapical cases. Furthermore, 31% of transfemoral patients were discharged directly home, compared to 21% of transapical patients.

Overall, the distribution of discharge destinations did not change considerably between 2012 and 2013.

Where can I learn more?

Visit our Valve Resource Center for the Cardiovascular Roundtable’s latest work on valve and TAVR program development. Also, make sure you’re subscribed to our blog as across the summer we’ll be releasing some additional insights on transcatheter valve procedures we gathered from the FY 2013 MEDPAR data.


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