Key result
Comprehensive Stroke Center status and trial participation are linked to higher reported post-TAVR stroke rates.
Why the study?
Hospital structural factors such as Comprehensive Stroke Center designation may affect stroke reporting after TAVR, impacting hospital performance assessment and public reporting.
Does hospital Comprehensive Stroke Center designation affect reported stroke rates in patients undergoing TAVR?
Observational (n=525,919)
Yes
Does hospital Comprehensive Stroke Center designation affect reported stroke rates in patients undergoing TAVR?
Hospital Comprehensive Stroke Center designation and TAVR trial participation are associated with higher reported stroke rates after TAVR, suggesting ascertainment bias that may impact hospital performance assessment.
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“The national TVT Registry uses a composite score, which includes the incidence of stroke to rank the quality of care at all US TAVI sites. Those sites with high-level stroke designation are penalised by the composite endpoint, since sites with lower-level stroke designation may be underreporting the incidence of stroke and, thus, have a better composite score and higher TAVI site quality rating.”
“This becomes an issue because stroke has been suggested as a nationally and publicly reported outcome measure for TAVI. Based on these data, stroke is not indicative of a universal quality issue. A death is a death. A transfusion is a transfusion. Stroke detection is inconsistent, and that variability will potentially put high-level stroke centres at a disadvantage in those quality measures.”
“Stroke is a publicly reported endpoint for TAVR centers. There may be a disincentive to report stroke, because centers that are theoretically doing a good job in reporting stroke might be put at a disadvantage in this public reporting model.”
Reported TAVR stroke rates may reflect ascertainment bias at Comprehensive Stroke Centers; leaves open true incidence and supports adjusted performance metrics.
BACKGROUND: The Michigan Structural Heart Consortium showed that transcatheter aortic valve replacement (TAVR) stroke rates were associated with hospital Comprehensive Stroke Center (CSC) designation, suggesting that hospital structural factors affect stroke reporting. We sought to determine whether CSC designation is nationally associated with reported stroke rates and the potential impact on hospital performance and Transcatheter Valve Therapy National Data Registry (TVTR) public reporting. METHODS: Consecutive TVTR cases from January 2016 through June 2023 were included, excluding sites reporting to the TVTR <1 year or performing <20 total TAVR procedures. The primary outcome was in-hospital stroke rate. Secondary outcomes were disabling stroke and 30-day stroke. Major bleeding, death, acute renal failure, and a composite end point were falsification end points to determine whether CSC status was uniquely associated with stroke. Multivariable hierarchical models were created starting with patient covariates and sequentially adding hospital variables to account for determinants of stroke. The impact of CSC status on hospital performance was estimated by correcting CSC hospital stroke rates in the validated TVTR 30-day composite model. RESULTS: A total of 525 919 TAVRs at 800 sites were included, and 10 963 strokes (2.1%) were reported within 30 days: 8284 (1.6%) in-hospital and 2679 (0.5%) after discharge. A total of 4733 (0.9%) were disabling strokes. Multivariate analysis showed that CSC status and participation in TAVR trials were independent predictors of in-hospital stroke rate ( P =0.033 and 0.012) and disabling stroke ( P =0.033 and 0.007), but not falsification end points ( P =NS). Participation in TAVR trials and operator volume were independent predictors of 30-day stroke ( P =0.039 and P =0.041). The impact of CSC status on the 30-day composite model showed performance improvement for 8 of 153 CSC hospitals. CONCLUSIONS: CSC hospital status and participation in TAVR trials are significant predictors unique for stroke. Correcting for the association of CSC status on stroke rate resulted in an estimated 8 of 153 hospitals improving their TVTR 30-day composite model performance. Further work is needed to account for potential ascertainment bias for stroke in public reporting.
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Deeb et al. (2026) conducted an observational in Transcatheter aortic valve replacement (TAVR) (n=525,919). Comprehensive Stroke Center (CSC) designation vs. Non-CSC designation was evaluated on In-hospital stroke rate (p=0.033). Hospital Comprehensive Stroke Center designation and participation in TAVR trials were independent predictors of reported in-hospital stroke rates (P=0.033 and P=0.012) after TAVR.
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