Hospital Volume and Selection of Valve Type in Older Patients Undergoing Aortic Valve Replacement Surgery in the United States

Abstract

Background— Hospital volume has been linked to quality of care. The relation between hospital volume and recommended use of bioprosthetic valves in older patients undergoing aortic valve replacement (AVR) is unknown. Methods and Results— We identified 80 470 patients aged ≥65 years undergoing isolated AVR (with or without bypass surgery) in 1045 US hospitals during 1999–2001 from Medicare Part A files. International Classification of Diseases, Ninth Revision, Clinical Modification codes were used to identify patients undergoing bioprosthetic valve (35.21) or mechanical valve (35.22) AVR. The sample was categorized into deciles on the basis of the valve surgery volume of the hospital. Generalized estimating equations determined the relative risk of receiving a bioprosthetic valve in different volume deciles, with adjustment for age, gender, race, comorbidity, and other factors. Bioprosthetic valve use increased ( P <0.001) from 44% in 1999 to 52% in 2001 and with age (from 36% in patients aged 65 to 69 years to 60% in patients aged ≥90 years). Rates were directly related ( P <0.001) to volume, rising from 28% in the 1st decile to 68% in the 10th decile. With the use of generalized estimating equations, the relative risk of bioprosthetic valve use, relative to the 1st decile, progressively increased from 1.2 (95% CI, 1.1 to 1.4) in the 2nd decile to 2.3 (95% CI, 1.9 to 2.7) in the 10th decile. Conclusions— Hospital volume was a strong predictor of bioprosthetic valve use in older patients undergoing AVR. The lower use of bioprosthetic valves in low-volume hospitals is at odds with recent guidelines recommending bioprosthetic valves in patients aged ≥65 years. These findings further support the use of volume as a marker of hospital quality.