Comparing post-operative resource consumption following transcatheter aortic valve implantation (TAVI) and conventional aortic valve replacement in the UK

Objective:

To define the in-hospital and 6-month post-discharge resource use, following Transcatheter Aortic Valve Implantation (TAVI) and conventional Aortic Valve Replacement (AVR) surgery within a single UK hospital.

Methods:

A local service evaluation of patients undergoing TAVI or AVR between January 2011 and May 2012 captured data until 6-months post-procedure, collected from hospital records and via a General Practitioner questionnaire. The main end-points were mortality, time in ITU/HDU, hospital length of stay (LoS), discharge destination, re-admission, and post-discharge primary/secondary care resource use. Sub-group analyses were performed for AVR patients aged ≥80 (AVR?≥?80) and with EuroSCORE of ≥10 (AVR ES?≥?10) to allow more direct comparison with ‘TAVI type’ patients.

Results:

Results are given as means (standard deviation) for TAVI (n?=?51), AVR (n?=?188), AVR?≥?80 (n?=?48), and AVR ES?≥?10 (n?=?47), respectively, unless otherwise stated. Age in years was 83.0 (8.1), 71.2 (13.1), 84.1 (2.7), 79.4 (7.1); EuroSCORE was 24.7 (11.9), 8.1 (6.4), 12.0 (6.0), and 16.5 (6.6); post-operative LoS (days) was 11.5 (11.2), 10.9 (10.8), 14.3 (16.7), and 15.2 (17.7). For discharged patients, 0%, 7%, 13%, and 9% had unplanned cardiac-related re-admissions within 30-days of discharge. Time to first readmission was 74.6 (34.0), 35.0 (34.2), 20.8 (9.7), and 22.6 (14.3) days.

Limitations:

This was a single-center retrospective evaluation, not prospectively powered to confirm differences in outcomes.

Conclusions:

Despite TAVI being performed in an older, higher risk population, LoS was similar to AVR. Most strikingly there were no cardiac-related re-admissions within 30-days for TAVI and time to first re-admission was significantly longer. This evaluation suggests that TAVI is clinically appropriate and provides economic advantages in both the hospital and post-discharge setting in this high risk group. Many patients undergoing TAVI are considered unfit for surgery and, hence, TAVI offers a treatment that delivers similar results to traditional AVR without the high risk associated with surgery.     

Resource utilization and procedure-related costs associated with transfemoral transcatheter aortic valve replacement

Aims: Transcatheter aortic valve implantation (TAVI) is an alternative to surgical valve replacement for patients with aortic stenosis (AS). This study assessed the impact of changing from a self-expandable (SE) valve to a balloon-expandable (BE) valve on healthcare resource use and procedural costs in a population of inoperable AS patients.

Methods: In this retrospective single center study, data for 195 patients who received either an SE or a BE valve between 2010–2014 were collected. Procedural and post-procedural healthcare resource use and cost parameters were determined for the two groups.

Results: The study showed that overall procedural time, including time required by medical personnel, was significantly shorter for TAVI using a BE compared with an SE valve. Post-surgery, patients in the BE valve group had significantly shorter hospital stays than the SE valve group, including significantly fewer days spent in the intensive care unit (ICU). Additionally, trends towards reduced 30-day mortality, incidence of new permanent pacemaker implantation, and incidence of blood transfusion were observed in the BE valve group compared with the SE valve group. Finally, total procedural costs were 24% higher in the SE compared with the BE valve group.

Limitations: The BE valve data were acquired in a single year, whereas the SE valve data were from a 5-year period. However, a year-by-year analysis of patient characteristics and study outcomes for the SE valve group showed few significant differences over this 5-year period.

Conclusions: Overall, changing from an SE to a BE valve for TAVI in patients with severe AS reduced both healthcare resource use and procedure-related costs, while maintaining patient safety. For healthcare providers, this could increase efficiency and capacity within the healthcare system, with the added advantage of reducing costs.     

Cost-effectiveness analysis of the SAPIEN 3 TAVI valve compared with surgery in intermediate-risk patients

Objective: Transcatheter aortic valve implantation (TAVI) has become the therapy of choice for treating severe aortic stenosis in patients at high-risk for surgery or where it is considered too risky to attempt. This uptake varies across geographies however, and its cost or value has frequently been cited as the reason for this. We sought to evaluate the potential cost and clinical impact of TAVI in intermediate risk patients from a French collective perspective.

Materials and methods: The analysis was performed using a novel Markov model with data derived from the PARTNER II randomized controlled trial for survival, clinical event rates, and quality-of-life. The simulated time horizon was 15?years, costs were from French sources and presented in 2016 Euros. Discounting of all outcomes was at 4% annually and the effect of uncertainty in model parameters was explored by deterministic and probabilistic sensitivity analysis (PSA).

Results: In comparison to surgery, TAVI resulted in improved clinical outcomes (life expectancy and quality-adjusted life expectancy) and lower costs over a lifetime time horizon. The base case results showed increases of 0.42?years and 0.41 QALYs with lifetime cost savings of €439 for TAVI compared to surgery. PSA results showed a >50% likelihood of cost-effectiveness at €0 willingness-to-pay and a 100% likelihood at ～€15,000.

Limitations: Clinically, survival projections are based on limited follow-up data and introduce uncertainty into the outcomes from the model. Economically, procedure costs are derived from a heterogeneous mix of patient risk groups, although this is much more likely to bias against TAVI and under-estimate overall cost savings.

Conclusions: In our analyses of intermediate risk patients, TAVI is associated with superior clinical outcomes compared to surgery and is cost saving. It could be expected that cost savings are conservative and likely to increase over time.     

Is transcatheter aortic valve implantation (TAVI) a cost-effective treatment in patients who are ineligible for surgical aortic valve replacement? A systematic review of economic evaluations

Objectives:

Health Technology Assessment (HTA) agencies often undertake a review of economic evaluations of an intervention during an appraisal in order to identify published estimates of cost-effectiveness, to elicit comparisons with the results of their own model, and to support local reimbursement decision-making. The aim of this research is to determine whether Transcatheter Aortic Valve Implantation (TAVI) compared to medical management (MM) is cost-effective in patients ineligible for surgical aortic valve replacement (SAVR), across different jurisdictions and country-specific evaluations.

Methods:

A systematic review of the literature from 2007–2012 was performed in the MEDLINE, MEDLINE in-process, EMBASE, and UK NHS EED databases according to standard methods, supplemented by a search of published HTA models. All identified publications were reviewed independently by two health economists. The British Medical Journal (BMJ) 35-point checklist for economic evaluations was used to assess study reporting. To compare results, incremental cost effectiveness ratios (ICERs) were converted to 2012 dollars using purchasing power parity (PPP) techniques.

Results:

Six studies were identified representing five reimbursement jurisdictions (England/Wales, Scotland, the US, Canada, and Belgium) and different modeling techniques. The identified economic evaluations represent different willingness-to-pay thresholds, discount rates, medical costs, and healthcare systems. In addition, the model structures, time horizons, and cycle lengths varied. When adjusting for differences in currencies, the ICERs ranged from $27K–$65K per QALY gained.

Conclusions:

Despite notable differences in modeling approach, under the thresholds defined by using either the local threshold value or that recommended by the World Health Organization (WHO) threshold value, each study showed that TAVI was likely to be a cost-effective intervention for patients ineligible for SAVR.