Association between patient survival and clinician variability in treatment rates for aortic valve stenosis

J. Matthew Brennan, Angela Lowenstern, Paige Sheridan, Isabel J. Boero, Vinod H. Thourani, Sreekanth Vemulapalli, Tracy Y. Wang, Otto Liska, Stuart Gander, Jason Jager, Martin B. Leon, Eric D. Peterson

Research output: Contribution to journalArticlepeer-review

3 Scopus citations


BACKGROUND: Patients with symptomatic severe aortic stenosis (ssAS) have a high mortality risk and compromised quality of life. Surgical/transcatheter aortic valve replacement (AVR) is a Class I recommendation, but it is unclear if this recommendation is uniformly applied. We determined the impact of managing cardiologists on the likelihood of ssAS treatment. METHODS AND RESULTS: Using natural language processing of Optum electronic health records, we identified 26 438 patients with newly diagnosed ssAS (2011–2016). Multilevel, multivariable Fine-Gray competing risk models clustered by cardiologists were used to determine the impact of cardiologists on the likelihood of 1-year AVR treatment. Within 1 year of diagnosis, 35.6% of patients with ssAS received an AVR; however, rates varied widely among managing cardiologists (0%, lowest quar-tile; 100%, highest quartile [median, 29.6%; 25th–75th percentiles, 13.3%–47.0%]). The odds of receiving AVR varied >2-fold depending on the cardiologist (median odds ratio for AVR, 2.25; 95% CI, 2.14–2.36). Compared with patients with ssAS of cardiologists with the highest treatment rates, those treated by cardiologists with the lowest AVR rates experienced significantly higher 1-year mortality (lowest quartile, adjusted hazard ratio, 1.22, 95% CI, 1.13–1.33). CONCLUSIONS: Overall AVR rates for ssAS were low, highlighting a potential challenge for ssAS management in the United States. Cardiologist AVR use varied substantially; patients treated by cardiologists with lower AVR rates had higher mortality rates than those treated by cardiologists with higher AVR rates.

Original languageEnglish (US)
Article numbere020490
JournalJournal of the American Heart Association
Issue number16
StatePublished - Aug 17 2021
Externally publishedYes


  • Aortic valve replacement
  • Physician variability
  • Symptomatic severe aortic stenosis

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine


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