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• W3135850006 abstract "There are limited data to support proposed increases to the minimum institutional mitral valve (MV) surgery volume required to begin a transcatheter mitral valve repair (TMVr) program. The current study examined the association between institutional MV procedure volumes and outcomes. All 2017 Medicare fee-for-service patients who received a TMVr or MV surgery procedure were included and analyzed separately. The exposure was institutional MV surgery volume: low (1 to 24), medium (25 to 39) or high (40+). Outcomes were in-hospital mortality and 1-year postdischarge mortality and cardiovascular rehospitalization. For MV surgery patients, in-hospital mortality rates were 6.4% at low-volume, 8.7% at medium-volume and 9.8% at high-volume facilities. Rates were significantly higher for low-volume [OR = 1.50, 95% CI (1.23 to 1.84)] and medium-volume [OR = 1.33, 95% CI (1.06 to 1.67)] compared with high-volume facilities. There was no statistically significant relationship between institutional MV surgery volume and in-hospital mortality for TMVr patients, either at low-volume [OR = 1.52, 95% CI (0.56, 4.13)] or medium-volume [OR = 1.58, 95% CI (0.82, 3.02)] facilities, compared with high-volume facilities. Across all volume categories, in-hospital mortality rates for TMVr patients were relatively low (2.3% on average). For both cohorts, the rates of 1-year mortality and cardiovascular rehospitalizations were not significantly higher at low- or medium-volume MV surgery facilities, as compared with high-volume. In conclusion, among Medicare patients, there was a relation between institutional MV surgery volume and in-hospital mortality for MV surgery patients, but not for TMVr patients. There are limited data to support proposed increases to the minimum institutional mitral valve (MV) surgery volume required to begin a transcatheter mitral valve repair (TMVr) program. The current study examined the association between institutional MV procedure volumes and outcomes. All 2017 Medicare fee-for-service patients who received a TMVr or MV surgery procedure were included and analyzed separately. The exposure was institutional MV surgery volume: low (1 to 24), medium (25 to 39) or high (40+). Outcomes were in-hospital mortality and 1-year postdischarge mortality and cardiovascular rehospitalization. For MV surgery patients, in-hospital mortality rates were 6.4% at low-volume, 8.7% at medium-volume and 9.8% at high-volume facilities. Rates were significantly higher for low-volume [OR = 1.50, 95% CI (1.23 to 1.84)] and medium-volume [OR = 1.33, 95% CI (1.06 to 1.67)] compared with high-volume facilities. There was no statistically significant relationship between institutional MV surgery volume and in-hospital mortality for TMVr patients, either at low-volume [OR = 1.52, 95% CI (0.56, 4.13)] or medium-volume [OR = 1.58, 95% CI (0.82, 3.02)] facilities, compared with high-volume facilities. Across all volume categories, in-hospital mortality rates for TMVr patients were relatively low (2.3% on average). For both cohorts, the rates of 1-year mortality and cardiovascular rehospitalizations were not significantly higher at low- or medium-volume MV surgery facilities, as compared with high-volume. In conclusion, among Medicare patients, there was a relation between institutional MV surgery volume and in-hospital mortality for MV surgery patients, but not for TMVr patients. The Federal Drug Administration's recent approval expansion of transcatheter mitral valve repair (TMVr) to patients with secondary mitral regurgitation (MR) prompted a reconsideration of the national coverage determination (NCD) for reimbursement by the US Medicare program. A subsequent multisociety consensus statement1Bonow RO O'Gara PT Adams DH Badhwar V Bavaria JE Elmariah S Hung JW Lindenfeld J Morris A Satpathy R Whisenant B Woo YJ 2019 AATS/ACC/SCAI/STS expert consensus systems of care document: operator and institutional recommendations and requirements for transcatheter mitral valve intervention: a joint report of the American Association for Thoracic Surgery, the American College of Cardiology, the society for cardiovascular angiography and interventions, and the society of thoracic surgeons.J Am Coll Cardiol. 2019; 76: 96-117PubMed Google Scholar recommended an increased threshold from ≥25 to ≥40 annual mitral valve (MV) surgeries before hospitals can establish a new TMVr program. However, there are limited data to justify the increase. Although a volume-outcome relationship has been shown for invasive MV surgical procedures,2Gammie JS O'Brien SM Griffith BP Ferguson TB Peterson ED. Influence of hospital procedural volume on care process and mortality for patients undergoing elective surgery for mitral regurgitation.Circulation. 2007; 115: 881-887Crossref PubMed Scopus (212) Google Scholar, 3Badhwar V Vemulapalli S Mack MA Gillinov AM Chikwe J Dearani JA Grau-Sepulveda MV Habib R Rankin JS Jacobs JP McCarthy PM Bloom JP Kurlansky PA Wyler von Ballmoos MC Thourani VH Edgerton JR Vassileva CM Gammie JS Shahian DM. Volume-outcome association of mitral valve surgery in the United States.JAMA Cardiol. 2020; 5: 1092-1101Crossref Scopus (15) Google Scholar it is unknown whether the same relationship exists for MV surgical volume and outcomes of TMVr, a minimally invasive procedure with a favorable safety profile compared with open surgery and generally performed by a different cardiac specialty.4Feldman T Foster E Glower DD Kar S Rinaldi MJ Fail PS Smalling RW Siegel R Rose GA Engeron E Loghin C Trento A Skipper ER Fudge T Letsou GV Massaro JM Mauri L. Percutaneous repair or surgery for mitral regurgitation.N Engl J Med. 2011; 364: 1395-1406Crossref PubMed Scopus (1287) Google Scholar, 5Barker CM Reardon MJ Reynolds MR Feldman TE. Association between institutional mitral valve procedure volume and mitral valve repair outcomes in Medicare patients.JACC: Cardiovasc Interv. 2020; 13: 1137-1139Crossref PubMed Scopus (3) Google Scholar, 6Vemulapalli S Prillinger J Thourani V Yeh RW. Mitral valve surgical volume and transcatheter mitral valve repair outcomes: impact of a proposed volume requirement on geographic access.J Am Heart Assoc. 2020; 9e016140Crossref PubMed Scopus (1) Google Scholar The objective of this study was to update the analysis done by Barker et al5Barker CM Reardon MJ Reynolds MR Feldman TE. Association between institutional mitral valve procedure volume and mitral valve repair outcomes in Medicare patients.JACC: Cardiovasc Interv. 2020; 13: 1137-1139Crossref PubMed Scopus (3) Google Scholar that examined the association between institutional MV procedure volumes and outcomes in Medicare patients. First, we confirmed the level of association between institutional MV surgery volume and in-hospital mortality for both MV surgery and TMVr patients. Second, we examined the volume-outcome relationship for longer-term outcomes of mortality and cardiovascular rehospitalization up to 1 year postdischarge. Patients enrolled in fee-for-service Medicare who received either a TMVr or MV surgery procedure in 2017 were included in the study. Data from January 1, 2017 through December 31, 2018 were derived from the 100% Medicare Limited Dataset Standard Analytic Files. The Medicare files contain detailed claims and beneficiary enrollment information including but not limited to diagnosis and procedure codes, facility ID, patient demographics, and death information. This study was exempt from institutional review board review under 45 CFR 46.101(b) as all data were de-identified and accessed in compliance with the Health Insurance Portability and Accountability Act. The primary outcome was in-hospital mortality. Postdischarge outcomes of mortality and cardiovascular rehospitalization up to 1 year were also examined. Cardiovascular rehospitalization was defined as ICD-10 codes I00-I99 in the primary position.7Rogers T Khan JM Edelman JJ Waksman R. Summary of the 2018 medicare evidence development & coverage advisory committee (MEDCAC) for transcatheter aortic valve replacement.Cardiovasc Revasc Med. 2018; 19: 964-970Crossref PubMed Scopus (5) Google Scholar The main predictor was 2017 MV surgery volume for the procedure hospital. Hospitals were categorized into 3 groups based on the current requirements and those recommended by the societies1Bonow RO O'Gara PT Adams DH Badhwar V Bavaria JE Elmariah S Hung JW Lindenfeld J Morris A Satpathy R Whisenant B Woo YJ 2019 AATS/ACC/SCAI/STS expert consensus systems of care document: operator and institutional recommendations and requirements for transcatheter mitral valve intervention: a joint report of the American Association for Thoracic Surgery, the American College of Cardiology, the society for cardiovascular angiography and interventions, and the society of thoracic surgeons.J Am Coll Cardiol. 2019; 76: 96-117PubMed Google Scholar to begin a TMVr program: low-volume (1 to 24 surgeries), medium-volume (25 to 39), and high-volume (40+). Hospital characteristics, including volumes, were obtained using the 2017 Definitive Healthcare Hospital & IDN Database. Definitive Healthcare uses a proprietary algorithm derived from the Centers for Medicare & Medicaid Services (CMS) Standard Analytical Files to estimate all-payor procedure volumes for US hospitals.8Fulton L Kruse CS. Hospital-based back surgery: geospatial-temporal, explanatory, and predictive models.J Med Internet Res. 2019; 21: e14609Crossref PubMed Scopus (4) Google Scholar Although only Medicare patients were examined for outcomes, hospital volume classifications were based on all-payer data since MV surgery is also performed on commercially-insured patients.9Bonnet V Boisselier C Saplacan V Belin A Gérard J Fellahi J Hanouz J Fischer M. The role of age and comorbidities in postoperative outcome of mitral valve repair: a propensity-matched study.Medicine (Baltimore). 2016; 95: e3938Crossref PubMed Scopus (8) Google Scholar, 10Schnittman SR Itagaki S Toyoda N Adams DH Egorova NN Chikwe J. Survival and long-term outcomes after mitral valve replacement in patients aged 18 to 50 years.J Thorac Cardiovasc Surg. 2018; 155 (96-102 e11)Abstract Full Text Full Text PDF Scopus (14) Google Scholar TMVr and MV surgery patients were analyzed as separate cohorts. Baseline patient and hospital characteristics were reported and tested for statistically significant differences at p <0.05 using chi-squared, Fisher's exact test, or t-test, as appropriate. For outcomes modeling, in-hospital mortality was analyzed using generalized estimating equations models and accounted for clustering by institution. Odds ratios (OR), 95% confidence intervals (CI) and p values were presented as measures of association. Postdischarge outcomes were depicted using Kaplan-Meier curves and analyzed using a Cox proportional hazard model with a robust sandwich estimator to adjust for institutional clustering. Cumulative martingale residuals plots and Kolmogorov-type supremum tests were used to confirm the proportional hazards assumption. Hazard ratios (HR), 95% CIs and p values were presented as measures of association. All outcome models were risk-adjusted using a propensity score based on patient [age, sex, race, region, 31 comorbidity indicators from the Elixhauser comorbidity index (ECI)11Elixhauser A Steiner C Harris DR Coffey RM. Comorbidity measures for use with administrative data.Med Care. 1998; 36: 8-27Crossref PubMed Scopus (5714) Google Scholar] and hospital (bed size, teaching status, region) characteristics, as well as two-way interactions among the hospital characteristics. Propensity score adjustment was used to allow for the inclusion of many potential confounders without impeding model convergence. To address the potential for underpowered analysis due to low TMVr procedure volumes and outcome events, a sensitivity analysis was performed using TMVr procedures in both 2017 and 2018 to further evaluate the relationship between MV surgical volume and TMVr in-hospital mortality. Analytic data sets were created using the Instant Health Data platform from Panalgo and all statistical analyses were conducted using SAS software version 9.4 (SAS Institute, Cary, North Carolina). In 2017, a total of 16,610 Medicare patients underwent MV surgery, with 14.3% of surgeries performed at low-volume facilities, 10.6% at medium-volume facilities, and 75.2% at high-volume facilities (Table 1). The majority of MV surgery patients were male (52.8%), white (85.9%), and 70.1 years on average. A total of 3,435 Medicare patients underwent TMVr (i.e., 6.9% at low-volume, 11.0% at medium-volume, 82.1% at high-volume facilities). The majority were white (88.8%) and the average age was 79.7 years. TMVr patients had a greater number of baseline comorbidities than MV surgery patients (mean ECI score = 7.2 vs 5.4, respectively). In both cohorts, there were statistically significant baseline differences in patient age, race, region and select ECI categories (Table 2) across hospital volume categories. There were also significant differences in hospital characteristics where patients at high-volume facilities were more likely to be treated at teaching hospitals with larger bed sizes in the Northeast or South Atlantic regions.Table 1Patient and hospital characteristics for MV surgery and TMVr patients by MV surgery institutional volumePatient and hospital characteristicsMV surgery patientsTMVr patientsMV surgery institutional volumeLow (n = 2,369)Medium (n = 1,758)High (n = 12,483)Low (n = 237)Medium (n = 379)High (n = 2,819)Age (years)aSignificant difference between low-volume and high-volume for MV surgery patients,cSignificant difference between low-volume and high-volume for TMVr patients,dSignificant difference between medium-volume and high-volume for TMVr patients69.7 ± 8.970.2 ± 9.070.1 ± 8.977.6 ± 9.478.7 ± 8.180.0 ± 8.7Women1123 (47.4%)829 (47.2%)5893 (47.2%)128 (54.0%)177 (46.7%)1352 (48.0%)Race⁎Significant difference between low-volume and high-volume for MV surgery patients,†Significant difference between medium-volume and high-volume for MV surgery patients,‡Significant difference between low-volume and high-volume for TMVr patients,§Significant difference between medium-volume and high-volume for TMVr patients White2004 (84.6%)1540 (87.6%)10730 (86.0%)205 (86.5%)329 (86.8%)2515 (89.2%) Black202 (8.5%)119 (6.8%)956 (7.7%)12 (5.1%)22 (5.8%)165 (5.9%) Hispanic40 (1.7%)20 (1.1%)134 (1.1%)–11 (2.9%)23 (0.8%) Asian41 (1.7%)15 (0.9%)184 (1.5%)––43 (1.5%) Unknown82 (3.5%)64 (3.6%)479 (3.8%)––73 (2.6%)Patient Region⁎Significant difference between low-volume and high-volume for MV surgery patients,†Significant difference between medium-volume and high-volume for MV surgery patients,‡Significant difference between low-volume and high-volume for TMVr patients,§Significant difference between medium-volume and high-volume for TMVr patients Midwest766 (32.3%)379 (21.6%)3040 (24.4%)66 (27.8%)78 (20.6%)557 (19.8%) Northeast279 (11.8%)338 (19.2%)2771 (22.2%)33 (13.9%)56 (14.8%)570 (20.2%) South831 (35.1%)678 (38.6%)4610 (36.9%)95 (40.1%)135 (35.6%)1038 (36.8%) West493 (20.8%)363 (20.6%)2062 (16.5%)43 (18.1%)110 (29.0%)654 (23.2%)Elixhauser scorecSignificant difference between low-volume and high-volume for TMVr patients5.3 ± 3.75.4 ± 3.65.4 ± 3.77.8 ± 4.17.4 ± 3.87.2 ± 3.9Hospital Region⁎Significant difference between low-volume and high-volume for MV surgery patients,†Significant difference between medium-volume and high-volume for MV surgery patients,‡Significant difference between low-volume and high-volume for TMVr patients,§Significant difference between medium-volume and high-volume for TMVr patients Northeast268 (11.3%)337 (19.2%)2797 (22.4%)33 (13.9%)57 (15.0%)573 (20.3%) South Atlantic368 (15.5%)336 (19.1%)2479 (19.9%)49 (20.7%)82 (21.6%)626 (22.2%) East North Central555 (23.4%)245 (13.9%)2044 (16.4%)65 (27.4%)37 (9.8%)298 (10.6%) East South Central154 (6.5%)137 (7.8%)896 (7.2%)–19 (5.0%)183 (6.5%) West North Central207 (8.7%)128 (7.3%)1224 (9.8%)–36 (9.5%)268 (9.5%) West South Central330 (13.9%)207 (11.8%)1022 (8.2%)41 (17.3%)33 (8.7%)205 (7.3%) Mountain205 (8.7%)150 (8.5%)613 (4.9%)26 (11.0%)50 (13.2%)201 (7.1%) Pacific282 (11.9%)218 (12.4%)1408 (11.3%)16 (6.8%)65 (17.2%)465 (16.5%)Bed size⁎Significant difference between low-volume and high-volume for MV surgery patients,†Significant difference between medium-volume and high-volume for MV surgery patients300 ± 149370 ± 179593 ± 312323 ± 183470 ± 179583 ± 289Teaching hospital⁎Significant difference between low-volume and high-volume for MV surgery patients,†Significant difference between medium-volume and high-volume for MV surgery patients,‡Significant difference between low-volume and high-volume for TMVr patients1303 (55.0%)1248 (71.0%)10511 (84.2%)172 (72.6%)320 (84.4%)2451 (86.9%)Note: Categorical baseline variables reported as frequencies (%) and continuous variables as means ± standard deviation; Numbers based on patient counts <11 not reported per Medicare data use agreement. MV = mitral valve; TMVr = transcatheter mitral valve repair. Significant difference between low-volume and high-volume for MV surgery patients† Significant difference between medium-volume and high-volume for MV surgery patients‡ Significant difference between low-volume and high-volume for TMVr patients§ Significant difference between medium-volume and high-volume for TMVr patients Open table in a new tab Table 2(a) Comorbidities for MV surgery and TMVr patients by MV surgery institutional volumePatient and hospital characteristicsMV surgery patientsTMVr patientsMV surgery institutional volumeLow (n = 2,369)Medium (n = 1,758)High (n = 12,483)Low (n = 237)Medium (n = 379)High (n = 2,819)AIDSaSignificant difference between low-volume and high-volume for MV surgery patients.––44 (0.4%)0––Alcohol abusebSignificant difference between medium-volume and high-volume for MV surgery patients.64 (2.7%)64 (3.6%)266 (2.1%)––41 (1.5%)Anemia294 (12.4%)205 (11.7%)1527 (12.2%)40 (16.9%)67 (17.7%)445 (15.8%)ArrhythmiaaSignificant difference between low-volume and high-volume for MV surgery patients.1114 (47.0%)873 (49.7%)6502 (52.1%)167 (70.5%)269 (71.0%)1962 (69.6%)CHF1098 (46.3%)803 (45.7)5739 (46.0%)177 (74.7%)282 (74.4%)2088 (74.1%)Chronic pulm disaSignificant difference between low-volume and high-volume for MV surgery patients.675 (28.5%)462 (26.3)3086 (24.7%)93 (39.2%)132 (34.8%)949 (33.7%)Coagulopathy191 (8.1%)154 (8.8)1047 (8.4%)35 (14.8%)48 (12.7%)365 (12.9%)Depression302 (12.7%)227 (12.9)1534 (12.3%)40 (16.9%)60 (15.8%)367 (13.0%)Diabetes (Comp)cSignificant difference between low-volume and high-volume for TMVr patients.385 (16.3%)275 (15.6)1865 (14.9%)58 (24.5%)82 (21.6%)538 (19.1%)Diabetes (Uncomp) cSignificant difference between low-volume and high-volume for TMVr patients.574 (24.2%)387 (22.0)2655 (21.3%)77 (32.5%)107 (28.2%)675 (23.9%)Drug abusebSignificant difference between medium-volume and high-volume for MV surgery patients.58 (2.4%)51 (2.9)257 (2.1%)––35 (1.2%)Fluid & electrolyte559 (23.6%)366 (20.8)2827 (22.6%)80 (33.8%)139 (36.7%)970 (34.4%)HTN (Comp)848 (35.8%)610 (34.7)4429 (35.5%)144 (60.8%)221 (58.3%)1666 (59.1%)HTN (Uncomp) bSignificant difference between medium-volume and high-volume for MV surgery patients.1470 (62.1%)1136 (64.6)7689 (61.6%)174 (73.4%)269 (71.0%)1920 (68.1%)Hypothyroidism cSignificant difference between low-volume and high-volume for TMVr patients.385 (16.3%)268 (15.2)2113 (16.9%)42 (17.7%)102 (26.9%)677 (24.0%)Iron anemiasaSignificant difference between low-volume and high-volume for MV surgery patients.37 (1.6%)54 (3.1)306 (2.5%)–17 (4.5)103 (3.7%)Liver disease119 (5.0%)106 (6.0)671 (5.4%)–23 (6.1)132 (4.7%)Lymphoma24 (1.0%)25 (1.4)146 (1.2%)––50 (1.8%)Metastatic cancer15 (0.6%)-98 (0.8%)––32 (1.1%)(b) Comorbidities for MV surgery and TMVr patients by MV surgery institutional volumePatient and hospital characteristicsMV surgery patientsTMVr patientsMV surgery institutional volumeLow (n = 2,369)Medium (n = 1,758)High (n = 12,483)Low (n = 237)Medium (n = 379)High (n = 2,819)Obesity392 (16.5%)272 (15.5%)1963 (15.7%)48 (20.3%)49 (12.9%)359 (12.7%)Other neuro disbSignificant difference between medium-volume and high-volume for MV surgery patients.167 (7.0%)130 (7.4%)769 (6.2%)19 (8.0%)32 (8.4%)252 (8.9%)Peripheral vasc disaSignificant difference between low-volume and high-volume for MV surgery patients.,bSignificant difference between medium-volume and high-volume for MV surgery patients.501 (21.1%)372 (21.2%)2938 (23.5%)111 (46.8%)139 (36.7%)1049 (37.2%)Paralysis24 (1.0%)15 (0.9%)125 (1.0%)––39 (1.4%)Peptic ulcer31 (1.3%)29 (1.6%)210 (1.7%)––57 (2.0%)Psychoses21 (0.9%)10 (0.6%)88 (0.7%)––12 (0.4%)Pulm circ disorder aSignificant difference between low-volume and high-volume for MV surgery patients.588 (24.8%)479 (27.2%)3471 (27.8%)105 (44.3%)141 (37.2%)1143 (40.5%)RA or CVD cSignificant difference between low-volume and high-volume for TMVr patients.114 (4.8%)87 (4.9%)685 (5.5%)21 (8.9%)25 (6.6%)158 (5.6%)Renal failure cSignificant difference between low-volume and high-volume for TMVr patients.503 (21.2%)370 (21.0%)2742 (22.0%)107 (45.1%)149 (39.3%)1090 (38.7%)Tumor139 (5.9%)107 (6.1%)841 (6.7%)23 (9.7%)32 (8.4%)260 (9.2%)Heart valve diseasey,z1685 (71.1%)1342 (76.3%)9803 (78.5%)213 (89.9%)326 (86.0%)2477 (87.9%)Weight Loss dSignificant difference between medium-volume and high-volume for TMVr patients.130 (5.5%)91 (5.2%)589 (4.7%)16 (6.8%)23 (6.1%)261 (9.3%)Note: Baseline comorbidities reported as frequencies (%); Numbers based on patient counts <11 not reported per Medicare data use agreement; CHF = congestive heart failure; Circ = circulation; Comp = complicated; CVD = cardiovascular disease; Dis = disease; HTN = hypertension; MV = mitral valve; Neuro = neurological; Pulm = pulmonary; RA = rheumatoid arthritis; TMVr = transcatheter mitral valve repair; Uncomp = uncomplicated; Vasc = vascular.a Significant difference between low-volume and high-volume for MV surgery patients.b Significant difference between medium-volume and high-volume for MV surgery patients.c Significant difference between low-volume and high-volume for TMVr patients.d Significant difference between medium-volume and high-volume for TMVr patients. Open table in a new tab Note: Categorical baseline variables reported as frequencies (%) and continuous variables as means ± standard deviation; Numbers based on patient counts <11 not reported per Medicare data use agreement. MV = mitral valve; TMVr = transcatheter mitral valve repair. Note: Baseline comorbidities reported as frequencies (%); Numbers based on patient counts <11 not reported per Medicare data use agreement; CHF = congestive heart failure; Circ = circulation; Comp = complicated; CVD = cardiovascular disease; Dis = disease; HTN = hypertension; MV = mitral valve; Neuro = neurological; Pulm = pulmonary; RA = rheumatoid arthritis; TMVr = transcatheter mitral valve repair; Uncomp = uncomplicated; Vasc = vascular. Propensity score adjusted results (Table 3) found a significant relationship between MV surgery volume and in-hospital mortality for MV surgery patients, but did not find a similar relationship for TMVr patients. For MV surgery patients, adjusted analyses showed in-hospital mortality rates to be significantly higher for both low-volume and medium-volume facilities, as compared with high-volume facilities. There was no statistically significant relationship between institutional MV surgery volume and in-hospital mortality for TMVr patients. Across all volume categories, the observed in-hospital mortality rate for TMVr patients was relatively low: 2.3% for all TMVr patients as compared with 7.2% for MV surgery patients. Figure 1 displays the differences in in-hospital mortality rates across hospital volume categories by patient cohort.Table 3MV and TMVr patient outcomes by MV surgery institutional volumeOutcomen (%) with eventComparisonMeasure of associationaOdds ratio for in-hospital mortality, hazard ratio for postdischarge mortality and cardiovascular hospitalization. CI = confidence interval. (95% CI)p valueMV surgery outcomes by MV surgery institutional volume (n = 16,610)In-hospital mortalityLow: 233 (9.8%)Med: 152 (8.6%)High: 802 (6.4%)Low vs High1.50 (1.23, 1.84)<0.01bStatistically significant at p <0.05.Medium vs High1.33 (1.06, 1.67)0.01bStatistically significant at p <0.05.Postdischarge mortalityLow: 209 (9.8%)Med: 160 (10.0%)High: 935 (8.0%)Low vs High1.16 (0.95, 1.41)0.15Medium vs High1.20 (0.98, 1.48)0.08Cardiovascular rehospitalizationLow: 600 (28.1%)Med: 436 (27.1%)High: 3042 (26.0%)Low vs High1.09 (0.98, 1.21)0.13Medium vs High1.05 (0.93, 1.19)0.40TMVr outcomes by MV surgery institutional volumes (n = 3,435)In-hospital mortalityLow: <11Med: 12 (3.2%)High: 62 (2.2%)Low vs High1.52 (0.56, 4.13)0.41Medium vs High1.58 (0.82, 3.02)0.17Postdischarge mortalityLow: 45 (19.5%)Med: 78 (21.3%)High: 583 (21.2%)Low vs High0.91 (0.57, 1.44)0.69Medium vs High1.01 (0.77, 1.33)0.93Cardiovascular rehospitalizationLow: 79 (34.2%)Med: 137 (37.3%)High: 1066 (38.7%)Low vs High0.71 (0.55, 0.92)0.01bStatistically significant at p <0.05.Medium vs High0.94 (0.78, 1.14)0.52Note: Numbers based on patient counts <11 not reported per Medicare data use agreement; Med = medium; MV = mitral valve; TMVr = transcatheter mitral valve repair.a Odds ratio for in-hospital mortality, hazard ratio for postdischarge mortality and cardiovascular hospitalization. CI = confidence interval.b Statistically significant at p <0.05. Open table in a new tab Note: Numbers based on patient counts <11 not reported per Medicare data use agreement; Med = medium; MV = mitral valve; TMVr = transcatheter mitral valve repair. The sensitivity analysis for TMVr in-hospital mortality inclusive of both 2017 and 2018 data confirmed the results of the main analysis. After more than doubling the sample size (n = 8,572), there was still no statistically significant relationship between institutional MV surgery volume and in-hospital mortality for TMVr patients, either at low-volume [OR = 0.95, 95% CI (0.44, 2.04)] or medium-volume [OR = 1.04, 95% CI (0.63, 1.71)] facilities, as compared with high-volume facilities. For postdischarge outcomes, with respect to both MV surgery and TMVr patients, the rates of mortality and cardiovascular rehospitalization were not significantly higher at low- or medium-volume institutions, as compared with high-volume institutions (Table 3, Figure 1). Of note, cardiovascular rehospitalization rates were significantly lower for TMVr patients treated at low-volume compared with high-volume institutions. There were no significant differences in cardiovascular rehospitalization rates for TMVr patients at medium-volume versus high-volume institutions. In accordance with our previously published findings,5Barker CM Reardon MJ Reynolds MR Feldman TE. Association between institutional mitral valve procedure volume and mitral valve repair outcomes in Medicare patients.JACC: Cardiovasc Interv. 2020; 13: 1137-1139Crossref PubMed Scopus (3) Google Scholar this updated analysis found a significant inverse relationship between hospital MV procedure volume and in-hospital mortality for MV surgery patients, but no relationship for TMVr patients. Furthermore, no significant relationships were observed between hospital MV surgical volumes and postdischarge outcomes (mortality, cardiovascular rehospitalizations) for both MV surgery and TMVr patients. This study adds to the growing body of literature2Gammie JS O'Brien SM Griffith BP Ferguson TB Peterson ED. Influence of hospital procedural volume on care process and mortality for patients undergoing elective surgery for mitral regurgitation.Circulation. 2007; 115: 881-887Crossref PubMed Scopus (212) Google Scholar, 3Badhwar V Vemulapalli S Mack MA Gillinov AM Chikwe J Dearani JA Grau-Sepulveda MV Habib R Rankin JS Jacobs JP McCarthy PM Bloom JP Kurlansky PA Wyler von Ballmoos MC Thourani VH Edgerton JR Vassileva CM Gammie JS Shahian DM. Volume-outcome association of mitral valve surgery in the United States.JAMA Cardiol. 2020; 5: 1092-1101Crossref Scopus (15) Google Scholar,5Barker CM Reardon MJ Reynolds MR Feldman TE. Association between institutional mitral valve procedure volume and mitral valve repair outcomes in Medicare patients.JACC: Cardiovasc Interv. 2020; 13: 1137-1139Crossref PubMed Scopus (3) Google Scholar, 6Vemulapalli S Prillinger J Thourani V Yeh RW. 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