Determinants of Unmet Demand for Surgery: The Case of Transcatheter Aortic Valve Replacement

OBJECTIVES: To examine the determinants of unmet transcatheter aortic valve replacement (TAVR) needs and their impact on patient survival among Medicare beneficiaries with aortic stenosis. METHODS: We developed a county-level mismatch score measuring the gap between actual TAVR procedures performed and expected need based on population differences. Counties were classified as metropolitan, semiurban, or rural. Factors associated with larger mismatches were identified, and mortality rates among aortic stenosis (AS) patients were examined in relation to mismatch scores. We analyzed Medicare data from 2016 to 2022 across 3129 US counties. The mismatch score was developed to account for population differences and county urbanicity classification. Statistical analyses identified factors associated with TAVR mismatch and its relationship to mortality outcomes. RESULTS: We found substantial geographic variation in TAVR delivery. Counties with higher TAVR mismatch scores showed associations with fewer TAVR-providing hospitals, less market concentration, higher AS prevalence, and lower household incomes. Counties with greater gaps between needed and actual TAVR procedures were also associated with higher mortality rates. This relationship between mismatch and mortality was particularly strong in semiurban counties. CONCLUSIONS: Our findings identify associations between TAVR access gaps and patient outcomes, as well as factors linked to these access patterns. Counties with higher TAVR mismatch scores showed correlations with healthcare capacity constraints, geographic location, and socioeconomic factors. These associations suggest that mismatches may be addressed through targeted approaches based on local needs to improve care delivery for patients with AS in regions currently experiencing access challenges.