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Research Letter |

Presentation on US Hospital Websites of Risks and Benefits of Transcatheter Aortic Valve Replacement Procedures FREE

Mariah L. Kincaid, BS1; Lee A. Fleisher, MD2,3; Mark D. Neuman, MD, MSc2,3
[+] Author Affiliations
1Tufts University School of Medicine, Boston, Massachusetts
2Department of Anesthesiology and Critical Care, Perelman School of Medicine of the University of Pennsylvania, Philadelphia
3Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
JAMA Intern Med. 2015;175(3):440-441. doi:10.1001/jamainternmed.2014.7392.
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Published online

Adequate presentation of risks and benefits of medical therapies is essential to informed decision making by patients.1 Transcatheter aortic valve replacement (TAVR) has been recently approved by the US Food and Drug Administration for the treatment of severe aortic stenosis among carefully selected patients; recent randomized clinical trials have identified important positive and negative outcomes of TAVR in these populations, including twice the risk of stroke for patients undergoing TAVR vs those undergoing open aortic valve replacement.2,3 Since 78% of all adults in the United States seek out health information online,4 we assessed the information regarding known risks and benefits of TAVR made available to the public on the websites of US hospitals currently performing TAVR procedures.

Between May 16 and June 25, 2014, we reviewed the websites of all 317 hospitals listed in the Society of Thoracic Surgeons and the American College of Cardiology’s Transcatheter Valve Therapy Registry using common search engines.5 One of us (M.L.K.) reviewed each site for English-language pages mentioning TAVR and abstracted information into a standardized form regarding terms related to 11 potential risks and 11 potential benefits of TAVR compared with open aortic valve replacement that we defined a priori based on our review of a major randomized trial.2,3 Fisher exact tests were calculated using Stata, version 12.0 (StataCorp LP), to determine statistical significance between certain categorical variables. In addition, we obtained information regarding hospital characteristics using data from the 2013 American Hospital Association Annual Survey. This study was deemed exempt from review by the Tufts University School of Medicine Institutional Review Board.

We identified functioning websites for all 317 hospitals listed on the Transcatheter Valve Therapy Registry; of these, we excluded 33 websites that had no English-language pages mentioning TAVR and 22 websites that only provided a link to information on TAVR hosted on another hospital’s website. Of the 262 hospitals with pages describing TAVR, 213 (81.3%) were nongovernmental, nonprofit institutions. A total of 214 (81.7%) hospitals had a major or minor teaching affiliation, 255 (97.3%) were located in an urban area, and 183 (69.8%) had more than 400 beds (Table). Nearly all the websites (260 [99.2%]) described at least 1 benefit of TAVR relative to open aortic valve replacement. The most common benefits mentioned were the lower degree of invasiveness of TAVR compared with open aortic valve procedures (mentioned in 250 websites [95.4%]), the potential for more rapid recovery (125 [47.7%]), the lack of requirement for cardiopulmonary bypass (120 [45.8%]), and improved quality of life (119 [45.4%]). Sixty-nine websites (26.3%) mentioned 1 or more risks of TAVR, which is significantly fewer than those mentioning benefits (P < .001). Risks listed on these websites included stroke or transient ischemic attack (mentioned on 48 websites [18.3%]), vascular complications (36 [13.7%]), death (31 [11.8%]), and unknown long-term valve durability (28 [10.7%]). Numerical quantitative information was provided more frequently for benefits than for risks (P < .001), with any benefit term quantified on 97 websites (37.0%) while any risk term was quantified on only 12 websites (4.6%) (Figure).

Table Graphic Jump LocationTable.  Characteristics of US Hospital Websites With Pages on Transcatheter Aortic Valve Replacement
Place holder to copy figure label and caption
Figure.
Description and Quantification of Transcatheter Aortic Valve Replacement (TAVR) Risks and Benefits Relative to Open Aortic Valve Replacement on 262 Hospital Websites

Terms indicate the 11 mentioned risks and 11 mentioned benefits of TAVR compared with open aortic valve replacement. Risks and benefits were defined a priori based on review of published clinical trial data. Light blue bars correspond to mentions of TAVR benefits on hospital websites; dark blue bars correspond to quantification of the TAVR benefit mentioned. Light orange bars correspond to mentions of TAVR risks on hospital websites; dark orange bars correspond to quantification of the TAVR risk mentioned.

Graphic Jump Location

Although US hospital websites universally discuss the benefits of TAVR, they rarely present information on the potential risks of this procedure to the public; of 262 websites reviewed, 99.2% included information on specific benefits of TAVR whereas only 26.3% presented any information on specific risks associated with this procedure. Moreover, while websites rarely presented quantitative information about either risks or benefits, benefits were quantified more frequently than risks. Our findings suggest that web-based advertising of TAVR to the public by hospitals may understate the established risks of this procedure and provide little context for the magnitude of those risks to inform patient decision making. Hospitals may promote appropriate use of TAVR by presenting more balanced information regarding TAVR’s risks and benefits.

Corresponding Author: Mark D. Neuman, MD, MSc, Department of Anesthesiology and Critical Care, Perelman School of Medicine of the University of Pennsylvania, 423 Guardian Ave, 1119A Blockley Hall, Philadelphia, PA 19104 (neumanm@mail.med.upenn.edu).

Published Online: January 12, 2015. doi:10.1001/jamainternmed.2014.7392.

Author Contributions: Dr Neuman and Ms Kincaid had full access to all the data in the study and take full responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Kincaid, Neuman.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Kincaid, Neuman.

Critical revision of the manuscript for important intellectual content: Fleisher, Neuman.

Statistical analysis: Kincaid, Neuman.

Obtained funding: Kincaid, Neuman.

Administrative, technical, or material support: Neuman.

Study supervision: Neuman.

Conflict of Interest Disclosures: None reported.

Funding/Support: This work was supported by grant K08 AG043548-03 from the National Institute on Aging (Dr Neuman) and the Foundation for Anesthesia Education and Research (Ms Kincaid).

Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Stacey  D, Légaré  F, Col  NF,  et al.  Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. 2014;1:CD001431.
PubMed
Leon  MB, Smith  CR, Mack  M,  et al; PARTNER Trial Investigators.  Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. N Engl J Med. 2010;363(17):1597-1607.
PubMed   |  Link to Article
Reynolds  MR, Magnuson  EA, Wang  K,  et al; PARTNER Trial Investigators.  Health-related quality of life after transcatheter or surgical aortic valve replacement in high-risk patients with severe aortic stenosis: results from the PARTNER (Placement of AoRTic TraNscathetER Valve) Trial (Cohort A). J Am Coll Cardiol. 2012;60(6):548-558.
PubMed   |  Link to Article
Anderson  JG.  Consumers of e-health: patterns of use and barriers. Soc Sci Comput Rev. 2004;22(2):242-248. doi:10.1177/0894439303262671.
Link to Article
Society of Thoracic Surgeons and the American College of Cardiology. Society of Thoracic Surgeons and American College of Cardiology Transcatheter Valve Therapy Registry (TVT).http://www.ncdr.com/tvt. Accessed May 30, 2014.

Figures

Place holder to copy figure label and caption
Figure.
Description and Quantification of Transcatheter Aortic Valve Replacement (TAVR) Risks and Benefits Relative to Open Aortic Valve Replacement on 262 Hospital Websites

Terms indicate the 11 mentioned risks and 11 mentioned benefits of TAVR compared with open aortic valve replacement. Risks and benefits were defined a priori based on review of published clinical trial data. Light blue bars correspond to mentions of TAVR benefits on hospital websites; dark blue bars correspond to quantification of the TAVR benefit mentioned. Light orange bars correspond to mentions of TAVR risks on hospital websites; dark orange bars correspond to quantification of the TAVR risk mentioned.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable.  Characteristics of US Hospital Websites With Pages on Transcatheter Aortic Valve Replacement

References

Stacey  D, Légaré  F, Col  NF,  et al.  Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. 2014;1:CD001431.
PubMed
Leon  MB, Smith  CR, Mack  M,  et al; PARTNER Trial Investigators.  Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. N Engl J Med. 2010;363(17):1597-1607.
PubMed   |  Link to Article
Reynolds  MR, Magnuson  EA, Wang  K,  et al; PARTNER Trial Investigators.  Health-related quality of life after transcatheter or surgical aortic valve replacement in high-risk patients with severe aortic stenosis: results from the PARTNER (Placement of AoRTic TraNscathetER Valve) Trial (Cohort A). J Am Coll Cardiol. 2012;60(6):548-558.
PubMed   |  Link to Article
Anderson  JG.  Consumers of e-health: patterns of use and barriers. Soc Sci Comput Rev. 2004;22(2):242-248. doi:10.1177/0894439303262671.
Link to Article
Society of Thoracic Surgeons and the American College of Cardiology. Society of Thoracic Surgeons and American College of Cardiology Transcatheter Valve Therapy Registry (TVT).http://www.ncdr.com/tvt. Accessed May 30, 2014.

Correspondence

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