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

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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 (PPConclusions— 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.