The current analysis demonstrates that the implementation of Benchmark best practices resulted in reduced LoS while maintaining patient safety in different European countries despite differences in healthcare systems and patients’ baseline characteristics. The adoption of an evidence-based and expert-informed streamlined hospital pathway for TAVI patients supported with a peer mentorship programme can increase access to care, hospital capacity and efficiency in treating patients with severe AS in most European countries while optimizing outcomes.

Prior to the implementation of Benchmark, Germany reported the longest hospital LoS compared to other countries. The close scrutiny of processes of care and the implementation of bundle of best practices was instrumental in achieving a 33% decrease, the highest improvement among all reported countries. The mean hospital LoS in Germany prior to Benchmark was 11.7 days, which is comparable to the average TAVI hospital LoS reported in Germany between 2020 (11.5 days) and 2022 (11.1 days) [13]. Similarly, in Italy, the median hospital LoS prior to Benchmark in our report was 7 days, which corresponds to the results of the multicentre Italian OBSERVANT TAVI registry (median 7 days) [14]. After the implementation of Benchmark in the participating Italian centres, the median hospital LoS was significantly reduced by 2 days, resulting in a median of 5 days. As for the intensive care LoS, there was no reduction documented in Italy, which may be explained by the fact that the intensive care stay prior to Benchmark was already low compared to the intensive care duration reported in the OBSERVANT registry (median 1 vs. 2 days). In France, on the other hand, the highest reduction in the intensive care LoS was observed – from median 1.1 days prior to Benchmark to close to 0 days after Benchmark, meaning that the majority of patients did not stay on an intensified care unit at all after TAVI. The total hospital LoS was also reduced from median 5 to 3 days. The recent analysis of the FRANCE 2 and FRANCE-TAVI registries as well as the single-payer national health data system (SNDS) reported a median LoS of 5 days in the period between 2010 and 2021, which corresponds to the number observed in our registry prior to the implementation of Benchmark best practices [15]. In Spain, a significant decrease in the total hospital LoS (median 6 to 4 days) and intensive care LoS (median 1.7 to 1 day) was observed as well. The median hospital LoS reported in the Spanish TAVI registry was 6 days, which, once again, corresponds with the duration of hospital admission recorded in our registry prior to the introduction of Benchmark best practices [16]. Thus, patients in this registry documented prior to the implementation of Benchmark had a hospital LoS similar to multiple other registries, which accurately reflects real world practice and indicates the effectiveness of Benchmark best practices in reducing hospital LoS in these patient populations.

The reduction in the total hospital LoS was observed in all considered countries, except for Austria, where neither the length of hospital stay nor intensive care stay were reduced. Notably, Austrian patients tended to have a sicker profile at baseline compared to other countries. These patients tended to be more symptomatic and having prior myocardial infarction, pulmonary hypertension, atrial fibrillation, LBBB, and LVEF < 50% more often. Interestingly, this finding is not reflected in the EuroSCORE II, which appeared to be on lower side of the spectrum (4.0 ± 3.8). However, the characteristics of the current Austrian population are different when comparing these patients to those included in the nationwide Austrian TAVI registry as well as the recent AUTHEARTVISIT study [17, 18]. The reason for this inconsistency may be the fact that the Austrian TAVI registry included patient data from 11 centres for interventional cardiology representing 100% of Austrian institutions offering TAVI by vascular access sites, whereas the AUTHEARTVISIT study included patient data from the Austrian Insurance funds from 2010 through 2020, making the profile of the Austrian patient population reported in the current analysis less representative.

Besides the decrease in hospital LoS, one major goal of the Benchmark implementation was to preserve safety after TAVI. In our report, the 30-day safety was uncompromised in all countries included, which reinforces the results published for the total BENCHMARK population [10]. Moreover, there was no increase in the rate of hospital readmission documented after the implementation of Benchmark best practices, despite earlier discharge. There was also a significant reduction in the rates of major vascular complications in Germany after the implementation of Benchmark best practices (5.9% vs. 0.0%). The rates of all-cause mortality were quite low across all countries (< 1.0%) before and also with the implementation of Benchmark best practices compared to the previously reported rates in other registries. For instance, the 30-day mortality in the combined analysis of French TAVI registries was 4.0% compared to 0.0% and 0.8% prior to and after Benchmark implementation, respectively [15]. Similarly, the Italian OBSERVANT registry reported the rates of 30-day mortality to be 6.7% in males and 5.1% in females as opposed to 1.1% prior to and 0.0% after Benchmark in our registry [14]. Same differences are observed when comparing the 30-day mortality rates from the Spanish, German, and Austrian TAVI registries with the rates presented here [16, 18, 19]. Lower mortality rates in our patient population may be partially attributed to the lower risk profile of TAVI patients, better device technology with the use of new generation valves as well as increased operator experience.

Streamlining care by shortening hospital LoS offers a number of benefits, including minimizing hospital costs and resources related to unnecessary hospitalization time and the positive outcomes of early mobilization. Furthermore, the risk of in hospital-acquired infections and hospital readmission at 30 days is also reduced when patients are discharged earlier after TAVI [20, 21]. Based on our findings and other reports, the main drivers of accelerated recovery and shortened hospital LoS include various preventive measures, such as determination of an anticipated discharge based on pre-procedural risk stratification, the use of cardiac catheterization laboratory and local anaesthesia with or without light procedural sedation, removal of the temporary pacemaker at the end of the procedure, post-procedure echo- or angiographic check to confirm proper closing of access site, and the reduced use of critical care facilities [9, 22, 23]. In addition, patient and family engagement to facilitate shared decision-making plays a crucial role in early discharge. It is important to note, however, that several factors, such as cultural norms and the challenges of change management, should be considered for the wider adoption of Benchmark best practices across various countries. For example, local reimbursement issues related to the fixed minimum hospital stay duration, lack of resources, or certain attitudes and ideologies may result in stronger resistance to change. However, the use of contemporary evidence, peer-to-peer coaching and strong focus on quality improvement and access to care demonstrated in the BENCHMARK registry may serve as facilitators to the broader implementation of a streamlined patient pathway.

From the economical perspective, TAVI itself has become a superior approach in terms of lower costs and better outcomes compared with surgery and the shorted hospital LoS adds an additional economic benefit to that. In the propensity-matched economic analysis of the 3M-TAVR registry, the minimalist clinical pathway led to ≈$11,000 lower cumulative costs at 30 days, of which > $8000 were saved in non-procedure related costs during the index hospitalization, driven primarily by shorter LoS [24]. A shorter hospital stay also allows additional hospital revenue by freeing up hospital beds for other patients [24]. While LoS is the major contributor to TAVI costs, the avoidance of general anaesthesia, resulting in shorter procedure times, and minimal use of critical care services result in further savings [25, 26]. The planned economic analysis of the BENCHMARK registry will further assess potential costs savings associated with the implementation of best practices across different healthcare systems.