Challenges for TAVR in Low-Population Density Areas

Results from a new analysis suggest that transcatheter aortic valve replacement (TAVR) in low-population density areas faces unique challenges.

“Restricting TAVR to centers based on volume thresholds alone can potentially create unintended disparities in healthcare access,” the authors wrote. “We aimed to compare the influence of population density in state of Florida in regard to access to TAVR, utilization rates, and in-hospital mortality.”

The paper, published in Circulation: Cardiovascular Quality and Outcomes, summarized study results collected between 2001 and 2016 from the Agency for Health Care Administration. Using this data, they tracked time and distance from participant home addresses to the zip code of their care facility. They then compared time and distance, utilization rates, and mortality across low and high population densities (pop. per square mile of land). The analysis included 6,531 patients (mean age 82, 43% female). Participants living in the lowest population density areas (<50 square miles of a facility) tended to be younger, male, and less likely to be a racial minority.

According to the analysis results, participants in the lowest density cohort saw longer driving distances and times to the care center (mean extra distance [miles]=43.5 [95% CI, 35.6 to 51.4]; P<0.001), longer mean extra time (min)=45.6 [95% CI, 38.3 to 52.9]; P<0.001), and these differences persisted regardless of methodology for determining population density. The authors reported a seven-fold difference in utilization rates in the lowest-density vs. highest-density regions (7 vs. 45 per 100,000; P<0.001 for pairwise comparisons). There was also increased procedure-related in-hospital mortality (adjusted OR=6.13; 95% CI, 1.97 to 19.1; P<0.001).

“Older patients living in rural counties in Florida face significantly longer travel distances and times for TAVR, lower utilization rates, and higher adjusted TAVR mortality, the authors concluded. “These findings suggest that there are trade-offs between access to TAVR, its rate of utilization, and procedural mortality, all of which are important considerations when defining institutional and operator requirements for TAVR across the country.”