Referral patterns and clinical outcomes in patients with severe aortic stenosis: A multicenter cohort study

Background

Patients with severe aortic stenosis (AS) require timely follow-up by cardiac specialists and aortic valve replacement (AVR). This multicenter study evaluates how the specialty of the provider who ordered the initial echocardiogram influences these endpoints.

Methods

Patients from 3 health systems with a first echocardiogram (index echo) diagnosing severe AS from Jan 1, 2019 to Dec 31, 2022, were categorized based on the specialty of the provider ordering the echo. Endpoints included a composite outcome of early cardiac follow-up or AVR (within 90 days), AVR during follow-up, and mortality. Logistic regression and Cox proportional hazard models were used to identify factors associated with the endpoints.

Results

4,249 patients (77 years; 58% male; 88% white; 72% symptomatic AS) were followed for a median of 552 days. Eighty-nine percent of patients achieved the composite outcome, yet 1,801 patients (42%) did not receive an AVR during the follow-up period, including 32% of symptomatic patients. Patients referred for the index echo by noncardiac specialty providers had lower rates of early cardiac follow-up or AVR (adjusted OR: 0.33, 95% CI, 0.25-0.43), lower AVR rates (adjusted HR: 0.59, 95% CI, 0.53-0.66), and higher mortality (adjusted HR: 1.65; 95% CI, 1.44-1.90) compared to the patients referred by a cardiology provider; the discrepancy was more pronounced in patients with low-flow, low-gradient AS.

Conclusion

In this large multicenter study of patients with severe AS, patients with a noncardiac specialty provider were less likely to receive timely cardiac follow-up and AVR, and had higher mortality. Initiatives to address disparities in care and improve outcomes for this high-risk population are needed.