Reimbursement policy and outcomes after transcatheter aortic valve implantation

Background: Transcatheter aortic valve implantation (TAVI) is an established treatment for severe aortic stenosis. While reimbursement policies significantly expand access, the impact of Taiwan's National Health Insurance (NHI) coverage introduced in February 2021 on patient characteristics and outcomes remains unclear. This study evaluates changes in patient profiles and clinical outcomes before and after NHI reimbursement. Methods: We compared patient profiles, procedural variables, and clinical outcomes, including 30-day complications and 1-year all-cause mortality, cardiovascular death, and rehospitalization for heart failure (HF). Risk was stratified using the Society of Thoracic Surgeons (STS) score. Results: We analyzed 467 patients undergoing TAVI at a tertiary referral center between May 2010 and April 2024. Patients were divided into pre-reimbursement (n=258) and post-reimbursement (n=209) groups. Reimbursement was associated with a shift toward higher-risk patients, reflected by an increase in median STS scores (5.9% to 7.2%, p =0.002) and a greater proportion of patients with STS score ≥8% (44.0% vs. 31.8%, p =0.019). Post-reimbursement patients had higher prevalence of dialysis (17.7% vs. 7.6%, p =0.001) and more commonly underwent valve-in-valve TAVI for degenerated bioprosthetic valves (8.4% vs. 2.7%, p =0.007). Despite of this higher-risk profile, hospital stay was significantly shorter post-reimbursement (7.0 vs. 12.0 days, p <0.001). Valve Academic Research Consortium-3 (VARC-3) defined thirty-day outcomes were similar, except for reduced acute kidney injury in post-reimbursement patients (1.0% vs. 6.6%, p =0.021). One-year mortality was unchanged, but HF rehospitalization decreased significantly (2.9% vs. 8.1%, p =0.017). After multivariable adjustment, high STS risk (≥8%) independently predicted worse one-year outcomes. Conclusion: In this single-treatment group experience, NHI reimbursement in Taiwan expanded TAVI access to higher-risk patients without compromising short- or mid-term mortality, and was associated with reduced heart failure readmission, especially among high-risk patients.