Transcatheter aortic valve replacement (TAVR), which was first performed in 2002, offers a less-invasive alternative to SAVR, avoiding the need for a sternotomy and cardiopulmonary bypass by delivering a bioprosthetic valve via a catheter. Pivotal early trials demonstrated the transformative potential of TAVR, showing a significant reduction in mortality for inoperable patients and non-inferiority to SAVR in high-risk cohorts. TAVR also appears to be an alternative for severe AS patients with high or even intermediate operative risk. Better survival outcomes of the procedures were shown in numerous randomized controlled trials.Taiwan launched the compulsory National Health Insurance program in 1995, encompassing nearly 100% of the population and including approximately 92% of healthcare facilities. The NHI offers comprehensive healthcare services, including outpatient visits, hospitalization, examinations, prescriptions, rehabilitation, and home care. In Taiwan, the reimbursement of TAVR was divided into three periods.First period (2013-2016): the first TAVR was adopted in Taiwan in 2013. During the period, the NHI only reimbursed the cost of hospital stay, and the procedure and medical device of TAVR were fully out-of-pocket (OOP).Second period (2017-2020): The cost of hospital stay was covered by the NHI, and the procedure of TAVR was reimbursed for high-risk patients or those aged ≥80 yr (which was €2,270.7 per procedure). The medical device was out-of-pocket (median cost: €31,142.8).Third period (2021-): The cost of the hospital stay and procedure fee (€2,270.7) of TAVR are covered by the NHI, but the cost of the medical device (€29,592.4) was reimbursed conditionally.Given the high cost, healthcare system reimbursement is crucial for both patients and hospitals. Therefore, it is essential to monitor and evaluate the long-term effects of such reimbursement policies to ensure they align with the best interests of patient health outcomes.

This was a quasi-experimental study that used the nationwide claims data, including admission, outpatient, and prescription records from 2012 to 2021, and linked it to the Cause of Death data via scrambled identification. Patients who underwent TAVR between January 1, 2013, and December 31, 2021, and had the primary or secondary diagnosis of severe aortic stenosis (AS) were included. Patients who received TAVR were defined as the index date and followed until event occurrence, death, or the end of the study period (December 31, 2021), whichever came first. Then, patients were divided into three groups via the date of the received procedure (2013-2016, 2017-2020, and 2021-).The primary endpoint of this study was the 30-day mortality following the index date of the TAVR procedure, as indicated by vital status data from Cause of Death records. Safety outcomes assessed 30 days post-procedure included acute kidney injury and vascular complications. Additionally, all-cause mortality and major adverse cardiovascular events (MACE)—a composite of stroke, myocardial infarction (MI), and cardiovascular (CV) death—were evaluated. Stroke was defined as a primary or secondary diagnosis of stroke, supported by computed tomography (CT) or magnetic resonance imaging (MRI) conducted within 7 days before or after the diagnosis date. CV death was defined based on vital status from Cause of Death data, specifically concerning cardiovascular-related causes of death.The Cox proportional hazard model was used to evaluate the association of the reimbursement period of TAVR with ACM. In evaluating health outcomes other than ACM (i.e., MACE and permanent pacemaker implantation), the Fine and Gray proportional sub-distribution hazard model was used to account for the competing risk of death. Adjusted hazard ratios for health outcomes are presented.

Among 1,161 TAVR patients (mean age 81.8 years; 53.9% female), 30-day mortality remained stable (4.4%), while vascular complications declined over time (5.6% → 2.2%). After adjusting for baseline characteristics, the results showed reimbursement expansion did not affect 30-day mortality but was associated with improved long-term outcomes (Table 1). Compared with the out-of-pocket period, the partial reimbursement strategy significantly reduced the risk of ACM (HR 0.75, 95% CI 0.59–0.95) and PPI (HR 0.56, 95% CI 0.41–0.76) (Table 2).

Progressive expansion of TAVR reimbursement of health insurance coverage improved long-term survival and reduced device-related complications without compromising short-term safety, highlighting the positive impact of equitable financial access on procedural outcomes.