Editorial
Hospital Readmission as a Transcatheter Aortic
Valve Replacement Performance Measure
Too Soon?
Rajesh V. Swaminathan, MD; Sunil V. Rao, MD
R ising healthcare costs and the identification of high-
risk patients who are frequent consumers of healthcare
resources have forced a spotlight on 30-day readmission
rates as a key quality metric by the Centers for Medicare
and Medicaid Services. This metric has quickly gained the
attention of hospital systems, which are subject to penalties
for higher than expected readmission rates. Several disease
processes have been tracked through the Affordable Care
Act’s Hospital Readmissions Reduction Program, including
acute myocardial infarction, congestive heart failure, chronic
obstructive pulmonary disease, and pneumonia.1 The exten-
sive efforts to define, track, and reduce readmission rates
coupled with complex payment adjustment formulas have all
been aimed at improving healthcare efficiency, quality, and
value of care delivered.
See Article by Kolte et al
Transcatheter aortic valve replacement (TAVR) for severe
aortic stenosis has become the treatment of choice for patients at
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high or prohibitive risk from traditional surgical valve replace-
ment. Although a continuously growing body of data has focused
on important short- and longer-term clinical outcomes, increas-
ingly important aspects of the procedure include processes of
care, clinical pathways, and patient-centered outcomes. In this
issue of Circulation: Cardiovascular Interventions, Kolte et al2
used the Nationwide Readmissions Database to characterize the
incidence, predictors, causes, and cost of 30-day TAVR readmis-
sion rates. The authors found that in 12 221 index TAVRs per-
formed at 210 centers in 2013, the primary outcome of 30-day
all-cause readmission rate was 17.9%.2 Based on this rate,
the authors propose that readmission rates after TAVR should
become a performance measure; however, several issues need
to be considered before hospitals are subjected to another metric
that potentially carries a financial risk.
Performance measures are aspects of quality that may
comprise structure, process, or outcomes. To be valid, a per-
formance measure must represent a meaningful metric to
The opinions expressed in this article are not necessarily those of the
editors or of the American Heart Association.
From the Division of Cardiology, Duke University Medical Center and
the Duke Clinical Research Institute, Durham, NC.
Correspondence to Sunil V. Rao, MD, The Duke Clinical Research
Institute, 508 Fulton St, (111A) Durham, NC 27705. E-mail sunil.rao@
duke.edu
(Circ Cardiovasc Interv. 2017;10:e004752.
DOI: 10.1161/CIRCINTERVENTIONS.116.004752.)
© 2016 American Heart Association, Inc.
Circ Cardiovasc Interv is available at
http://circinterventions.ahajournals.org
DOI: 10.1161/CIRCINTERVENTIONS.116.004752
1
patients and society. In addition, it should be reliable and
practical to measure. Notably, there must be a risk adjustment
method to account for patient variability and confounders.
The most important aspect is that the performance measure
should be modifiable through practical implementation of new
or changed care processes.3 In this context, the consideration
of TAVR readmissions begs 3 questions: (1) is there realistic
room to reduce readmission rates?, (2) what are the possible
interventions to accomplish the reduction?, and (3) will reduc-
ing short-term TAVR readmissions improve value for this
patient population and support readmission as an appropriate
performance measure for hospitals performing TAVR?
To address the first question, it is important to put TAVR
readmission rates into perspective. The Table displays the 2013
30-day all-cause readmission rates after hospitalization for the
most commonly tracked diagnoses, including acute myocardial
infarction, pneumonia, chronic obstructive pulmonary disease,
and congestive heart failure.4 The current study shows that TAVR
readmissions are within this range. Nationally, temporal trends
in readmissions for cardiac-related conditions of acute myocar-
dial infarction and congestive heart failure have decreased 13%
and 6%, respectively, over the preceding 4 years.4 However,
total readmission rates across all index admissions for any cause
did not change from 2009 to 2013.4 Interestingly, there has been
a decline in all-cause readmission rates during the same 4 years
when stratified by Medicare patients only.4 This suggests that
readmissions for elderly patients, even with greater comorbidi-
ties, are preventable and not necessarily inevitable. Although
these are the patients who would be expected to have the high-
est readmission rates because of a greater number of comor-
bid conditions, they also have the most to gain from preventive
interventions. On the contrary, the TAVR readmission rate of
17.9% is identical to a more recent statistic showing that any
Medicare patient has an all-cause 30-day readmission rate of
17.8%.5 Therefore, it is somewhat reassuring that the rates of
readmission after TAVR, which is often performed in the sick-
est of patients, are not higher than the general readmission rates
for the Medicare population. These numbers speak to the over-
all safety of TAVR procedures and imply that readmission may
be independent of the procedure itself.
Nevertheless, efforts to reduce readmissions are important
and relevant to improving the value of care. What possible
interventions could accomplish the reductions? Interventions
should be targeted at the root causes and predictors of readmis-
sions. Kolte et al2 have found that a majority (≈60%) of TAVR
readmissions are not cardiac. Respiratory-related conditions,
infections, and bleeding were the most common noncardiac
etiologies of readmissions. Some of these readmissions may
 2   Swaminathan and Rao   Readmission as a TAVR Performance Measure
Table.  30-Day All-Cause Readmission Rates (2013)
Rate of All-Cause
Diagnosis/Procedure Readmission, %
Acute myocardial infarction* 14.7
Pneumonia* 15.5
Transcatheter aortic valve replacement† 17.9
Chronic obstructive pulmonary disease* 20.0
Congestive heart failure* 23.5
*Data from the Healthcare Cost and Utilization Project, Agency for Healthcare
Research and Quality.4
†Data from the Nationwide Readmissions Database.2
abate as TAVR technology improves. For example, bleeding
rates have dropped significantly6 because newer generation
TAVR systems involve lower profile sheaths associated with
less vascular complications. Infection rates may likewise drop
as the need for femoral surgical cutdowns decrease. These
advances, coupled with shorter procedure times, are allowing
centers to use moderate or deep sedation as opposed to gen-
eral anesthesia, a move that may further reduce infections and
mitigate respiratory readmissions.
The most common cardiac reason for TAVR readmis-
sion was found to be heart failure, accounting for 22.5% of
all readmissions. Several solutions are being tested to reduce
congestive heart failure readmissions, such as mobile health
technologies,7 community-based care transition teams, and
home demonstration projects. Whether these are successful
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or applicable to the TAVR patient remains to be studied. One
aspect of the TAVR procedure that may help is the involve-
ment of a dedicated multidisciplinary heart team for pre,
intra, and postprocedure early follow-up. In addition, these
patients tend to have strong family and social support, given
the number of clinic visits and preprocedure testing inherent
in a TAVR work-up. Leveraging this support network may be
central to reducing readmission rates, although the primary
mechanisms still need to be elucidated.
One interesting aspect of Kolte et al’s study is that there
seems to be striking hospital-level variability in 30-day TAVR
readmissions ranging from 0% to 50%. A similar range was
found even when the analysis was restricted to those programs
performing ≥5 or 10 annual TAVRs. Obtaining more granu-
lar information about the patient population and procedural
characteristics at these existing hospitals with low readmis-
sion rates would help inform future interventions for reducing
30-day TAVR readmissions, but it will be more important to
understand whether there is a volume–outcome relationship
with respect to readmission rates.
The final question is whether reducing short-term TAVR
readmissions is the right metric that will improve value for this
patient population. Healthcare value can be broadly defined as
health outcomes per dollar spent.8 Although it is true that read-
missions are costly, the issue ultimately is whether they meet
criteria for a performance measure and whether penalizing
hospitals for not meeting the metric results in improvement.
As noted earlier, certain aspects of readmissions are consistent
with the criteria for a performance measure—it is an outcome
that is important from a patient and societal perspective and is
relatively straightforward to measure using available admin-
istrative databases. However, risk adjustment and modifiable
risk factors remain a challenge. Moreover, several other stud-
ies have shown that certain performance measures may not
correlate with improved long-term outcomes. For example,
professional societies and hospitals have made significant
strides in improving door-to-balloon times for primary per-
cutaneous coronary intervention for ST-segment–elevation
myocardial infarction. After just a few years, >90% of patients
from a collection of hospitals met the metric,9 yet some stud-
ies indicate that ST-segment–elevation myocardial infarc-
tion mortality rates are relatively unchanged.10 In the setting
of nonsystem reasons for delay, similar mortality risk exists
whether the door-to-balloon time was >90 or ≤90 minutes.11
Potentially costly penalties, a key feature of the Hospital
Readmissions Reduction Program, are designed to motivate
hospitals to improve their quality of care and reduce pre-
ventable readmissions. Over the 3-year phase of HRPP, the
Centers for Medicare and Medicaid Services dollar estimates
of total penalties have increased from $290 million to $428
million.12 Indeed, readmission rates for conditions targeted
by the Hospital Readmissions Reduction Program have fallen
more rapidly than conditions not targeted by the program,
though nontargeted condition readmission rates have also
declined.13 This suggests that system-level changes are more
responsible for the decline than condition-specific improve-
ments. Despite creative measures by health systems to reduce
readmission rates, nearly 80% of hospitals in the program con-
tinue to receive penalties.12 The majority of hospitals receiving
the highest penalties are large hospitals, teaching hospitals,
and safety net hospitals.14 Readmission reductions are dif-
ficult in these settings, perhaps, because these hospitals dis-
proportionately treat patients of lower socioeconomic status
and higher complexity. Policy reform to account for the vari-
ability in hospital characteristics and associated readmission
rates will be complex. Although reducing financial resources
to lower-performing hospitals through penalties could nega-
tively impact their delivery of patient care, softening penal-
ties for these hospitals would hold them to a lower standard
and unintentionally weaken incentives for those programs to
improve health outcomes.12
The study by Kolte et al2 provides invaluable information
for patients, practitioners, and hospitals seeking to improve
long-term outcomes from TAVR. Using the current data to
develop risk calculators for TAVR readmissions may help
identify patients who may require further support after hos-
pital discharge. Although it may seem attractive to use read-
missions as a performance measure, further work is needed to
define modifiable risk factors and develop robust risk adjust-
ment before the implementation of programs that may penal-
ize hospitals for higher readmission rates. Given the rate at
which TAVR indications are rapidly expanding, and the con-
comitant costs that this may impose on the healthcare system,
the day when hospitals are held responsible for TAVR read-
missions is likely not far off. The study by Kolte et al2 is a big
step in preparing the field for that day.
Disclosures
None.
 3   Swaminathan and Rao   Readmission as a TAVR Performance Measure
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KEY WORDS: Editorials ◼ aortic valve stenosis ◼ heart failure ◼ medicare
◼ outcome and process assessment