We developed a feasible set of quality indicators for TAVI and found overall high quality of care but with some variation in practice, with QI adherence associated with reduced composite endpoint of mortality or rehospitalisation, though variation in clinical outcomes between hospitals was not attributable to variation in QI attainment.
Key Findings
Results
Five feasible quality indicators (QIs) were identified for TAVI from an internationally agreed set, with the majority showing high compliance and minimal variation across hospitals.
Data from 9748 TAVI procedures were included between 2018 and 2023 in Ontario, Canada.
The study used all-comer registry data from the provincial CorHealth registry linked to administrative datasets.
The lone exception to high compliance was performance of transfemoral TAVI without general anaesthesia (median 0.87; IQR 0.78–0.93).
The study setting was a universal publicly funded healthcare system covering all Ontario residents.
Results
Multidisciplinary heart team involvement in the TAVI procedure was the most strongly associated QI with reduced composite endpoint of all-cause mortality or rehospitalisation at 1 year.
Multidisciplinary heart team was defined as the presence of an interventional cardiologist and a cardiac surgeon.
OR 0.67, 95% CI 0.50 to 0.90, p=0.007 for the composite endpoint.
The primary endpoint was a composite of all-cause mortality or rehospitalisation at 1 year from the date of TAVI.
Association was examined using multivariable hierarchical logistic models.
Results
Performance of transfemoral TAVI without general anaesthesia was associated with a significant reduction in the composite endpoint of mortality or rehospitalisation at 1 year.
OR 0.80, 95% CI 0.71 to 0.91, p<0.0004.
This QI showed the greatest variation across hospitals (median 0.87; IQR 0.78–0.93).
This was the only QI with notable inter-hospital variation among the five feasible QIs identified.
Results
Utilisation of transfemoral access was associated with a reduction in the composite endpoint, though this did not reach statistical significance.
OR 0.84, 95% CI 0.69 to 1.04, p=0.10.
This QI was one of five feasible QIs derived from internationally agreed indicators.
The association trended toward benefit but failed to meet conventional thresholds for statistical significance.
Results
Variation in clinical outcomes following TAVI between hospitals was not attributable to variation in QI attainment.
Median ORs were used to assess whether between-hospital variation in clinical outcomes was explained by QI attainment.
The authors note that differences in patient factors partially explained variation in practice.
This finding indicates that other unmeasured factors beyond QI adherence drive outcome differences between centers.
Conclusions
The study identified overall high quality of TAVI care in Ontario, with some variation in practice partly attributable to differences in patient factors.
The cohort included 9748 TAVI procedures from 2018 to 2023.
The majority of QIs demonstrated high compliance with minimal inter-hospital variation.
The authors conclude that QIs can inform quality improvement by distinguishing discretionary from non-discretionary variation.
Ontario's universal healthcare system provided population-level all-comer data without selection bias.
What This Means
This research examined whether specific quality indicators (QIs) — measurable standards of good medical care — could be used to assess and compare the quality of transcatheter aortic valve implantation (TAVI), a minimally invasive heart valve replacement procedure, across hospitals in Ontario, Canada. Using data from nearly 10,000 TAVI procedures performed between 2018 and 2023, the researchers identified five practical quality measures and tested whether hospitals that followed these measures more consistently had better patient outcomes, specifically lower rates of death or rehospitalisation within one year.
The study found that most quality indicators were followed at high rates across Ontario hospitals, suggesting generally good care. However, one indicator — performing transfemoral (through the groin) TAVI without general anaesthesia — varied more between hospitals than the others. Patients whose care met these quality standards tended to have better outcomes: in particular, having both an interventional cardiologist and a cardiac surgeon involved in the procedure was associated with a 33% lower odds of death or rehospitalisation, and avoiding general anaesthesia during femoral-access TAVI was associated with a 20% lower odds of the same outcome. Despite these associations, the differences in patient outcomes between hospitals could not be fully explained by differences in how well hospitals followed the quality indicators, suggesting that other unmeasured factors — including differences in patient characteristics — also play an important role.
This research suggests that quality indicators can be a useful tool for identifying areas where TAVI care might be improved, particularly by highlighting variation in practices like anaesthesia use during certain procedures. However, the findings also caution that quality indicators alone do not capture the full picture of why outcomes differ between hospitals. Future work distinguishing between variation that reflects genuine differences in care quality versus variation driven by patient complexity will be important for using these measures fairly and effectively in quality improvement efforts.
Aktaa S, Haldenby O, Qiu F, Ko D, Fremes S, Sud M, et al.. (2026). Quality indicators for transcatheter aortic valve implantation in Ontario, Canada: a population-based study.. BMJ open. https://doi.org/10.1136/bmjopen-2026-123640