Whether or not a patient receives TAVR over SAVR might be more influenced by market forces than clinical evidence, after a recent study found that the more competitive the hospital market, the higher the TAVR likelihood, regardless of guideline recommendations.
- TAVR is widely considered equivalent to surgery in short-term outcomes, but durability concerns have begun to emerge as the technology matures.
- As a result, the 2020 ACC/AHA guidelines maintain Class 1A recommendations for surgical valve replacement in younger patients (≤65 years).
- Market competition has historically influenced surgical technology, with TAVR being no exception as younger patients seem more keen to accept it regardless of guidelines.
Examining 137k patients undergoing aortic valve replacement across seven states, researchers calculated hospital market competition using the Herfindahl-Hirschman Index and found that 61% of patients were treated at high-competition centers while revealing a troubling pattern.
- Treatment at a high-competition hospital conferred 68% increased relative risk of receiving TAVR versus surgery.
- Market competition effects were most pronounced among younger patients: under 50 years (aOR: 1.54) and 50-59 years (aOR: 1.30).
- Meanwhile the effects of market competition were smaller in older patient groups like 60-69 years (aOR: 1.13), 70-79 years (aOR: 1.10), and 80+ years (aOR: 1.18).
- Among patients under 50, TAVR use at competitive centers grew from 7% in 2016 to 15% in 2021.
Even with patient preference surveys showing approximately 80% of patients favor TAVR for reduced invasiveness and presumed shorter recovery, the market-driven utilization among younger patients represents a break from consensus recommendations.
- This hints at an uncomfortable, but practical reality in which surgeons and hospitals may feel compelled to offer TAVR to meet patient and market demands.
That said, it isn’t a good sign that hospital systems are willing to forgo guidelines in favor of appeasing patients when we still don’t know what TAVR reintervention rates look like beyond 20 years.
The Takeaway
This analysis exposes market competition as a powerful driver of TAVR adoption among younger patients despite lacking long-term durability evidence. It seems like the saying “the customer is always right” has found its way into aortic valve replacement, a place where it might not belong.
