Systematic review of model-based economic evaluations of heart valve implantations

Decision analysis in cardiac surgery: a scoping review and methodological primer

OBJECTIVES

Randomized controlled trials are the gold standard for evidence generation in medicine but are limited by their real-world generalizability, resource needs, shorter follow-up durations and inability to be conducted for all clinical questions. Decision analysis (DA) models may simulate trials and observational studies by using existing data and evidence- and expert-informed assumptions and extend analyses over longer time horizons, different study populations and specific scenarios, helping to translate population outcomes to patient-specific clinical and economic outcomes. Here, we present a scoping review and methodological primer on DA for cardiac surgery research.

METHODS

A scoping review was performed using the PubMed/MEDLINE, EMBASE and Web of Science databases for cardiac surgery DA studies published until December 2021. Articles were summarized descriptively to quantify trends and ascertain methodological consistency.

RESULTS

A total of 184 articles were identified, among which Markov models (N = 92, 50.0%) were the most commonly used models. The most common outcomes were costs (N = 107, 58.2%), quality-adjusted life-years (N = 96, 52.2%) and incremental cost-effectiveness ratios (N = 89, 48.4%). Most (N = 165, 89.7%) articles applied sensitivity analyses, most frequently in the form of deterministic sensitivity analyses (N = 128, 69.6%). Reporting of guidelines to inform the model development and/or reporting was present in 22.3% of articles.

CONCLUSION

DA methods are increasing but remain limited and highly variable in cardiac surgery. A methodological primer is presented and may provide researchers with the foundation to start with or improve DA, as well as provide readers and reviewers with the fundamental concepts to review DA studies.

Cost-effectiveness analysis of a resource-intensive approach versus minimally invasive strategy for high-risk transcatheter aortic valve replacement patients

Aortic stenosis has a high mortality rate in patients who do not receive aortic valve replacement. Previously, transcatheter aortic valve replacement (TAVR) was an intervention reserved for individuals deemed high-risk for surgery. Since that time, TAVR has increasingly been offered to lower risk patients, yet it is unclear whether TAVR will meet an acceptable cost-effectiveness threshold in this group. In this cost-effectiveness study, we employed a decision tree model with Monte Carlo probability sensitivity analysis to determine the incremental cost (in US$) per quality-adjusted life year (QALY) and life year (LY) of performing the TAVR procedure using the resource-intensive approach versus the minimally invasive strategy in high-risk surgical patients.

The fundamentals of health economics and its application in the provision of vascular surgery in the UK

Health economics offers a lifeline to policymakers as a way of improving health outcomes in the face of increased monetary constraints. Doctors are uniquely placed in healthcare delivery where they have a pertinent influence on both supply and demand for healthcare provisions. Every clinical decision made by doctors is also an economic decision, and the true cost of offering a scarce healthcare resource includes not being able to fund alternative therapies and hence, foregoing its benefit. Technology and innovation in medicine is seeing an increase in potential therapies; however, how well do they perform against the current gold standard and are they worth the additional cost? A personalized and patient-centered approach to medicine has paved the way for a holistic health outcome measure, quality-adjusted life years, which is predominately used by United Kingdom resource allocators. Aortic surgical interventions are resource-intensive, and recent trends have shown the growing economic burden as yearly costs continue to climb. Health economic models are not without their weaknesses and it is important that future analyses assess the impact on society, distributional consequences, and the value of collecting more information to reduce the uncertainty of the economic result.

Cardiac-CT and cardiac-MR cost-effectiveness: a literature review

Cardiovascular diseases are still among the first causes of death worldwide with a huge impact on healthcare systems. Within these conditions, the correct diagnosis of coronary artery disease with the most appropriate imaging-based evaluations is of utmost importance. The sustainability of the healthcare systems, considering the high economic burden of modern cardiac imaging equipments, makes cost-effective analysis an important tool, currently used for weighing different costs and health outcomes, when policy makers have to allocate funds and to prioritize interventions, getting the most out of their financial resources. This review aims at evaluating cost-effective analysis in the more recent literature, focused on the role of Calcium Score, coronary computed tomography angiography and cardiac magnetic resonance.

Next-generation tissue-engineered heart valves with repair, remodelling and regeneration capacity

Valvular heart disease is a major cause of morbidity and mortality worldwide. Surgical valve repair or replacement has been the standard of care for patients with valvular heart disease for many decades, but transcatheter heart valve therapy has revolutionized the field in the past 15 years. However, despite the tremendous technical evolution of transcatheter heart valves, to date, the clinically available heart valve prostheses for surgical and transcatheter replacement have considerable limitations. The design of next-generation tissue-engineered heart valves (TEHVs) with repair, remodelling and regenerative capacity can address these limitations, and TEHVs could become a promising therapeutic alternative for patients with valvular disease. In this Review, we present a comprehensive overview of current clinically adopted heart valve replacement options, with a focus on transcatheter prostheses. We discuss the various concepts of heart valve tissue engineering underlying the design of next-generation TEHVs, focusing on off-the-shelf technologies. We also summarize the latest preclinical and clinical evidence for the use of these TEHVs and describe the current scientific, regulatory and clinical challenges associated with the safe and broad clinical translation of this technology.

Present and future economic impact of transcatheter aortic valve replacement on the Portuguese national healthcare system

INTRODUCTION

Transcatheter aortic valve replacement (TAVR) has changed the treatment paradigm of severe aortic stenosis (AS). Nevertheless, in Portugal the penetration rate of TAVR is still very low and there is a paucity of data regarding its economic impact on the Portuguese healthcare system.

AIMS

To perform an economic analysis of the present and future impact of TAVR in Portugal and to propose health policy recommendations for a new reimbursement model.

METHODS

Hospital data from a high-volume center were used as a sample to calculate the costs of TAVR in Portugal. Information regarding the national penetration rate was derived from the EAPCI Valve for Life initiative. To estimate the future demand for TAVR, three scenarios (S) were constructed: S1, TAVR penetration according to current guidelines; S2, including intermediate-risk patients; and S3, including low-risk patients aged over 75 years.

RESULTS

The total cost of each TAVR procedure in Portugal was 22 134.50 euros for the self-expanding valve (SEV) and 23 321.50 euros for the balloon-expanding valves (BEV). Most of the cost was driven by the price of the valve (SEV 74.5% vs. BEV 81.5%). The current national economic impact is estimated at 12 500 000 euros per year. In S1, the expected penetration rate would be 189 procedures per million population; in S2 we estimated an increase of 28% to 241 procedures per million population and in S3 an increase of 107% to 391 procedures per million population. The total economic impact would increase to 43 770 586 euros in S1 and to 90 754 310 euros in S3.

CONCLUSIONS

TAVR is associated with a significant present and future economic impact on the Portuguese healthcare system. A new model of reimbursement in Portugal should be discussed and implemented.

Cost Analysis in Shoulder Surgery: A Systematic Review

BACKGROUND

Cost analysis studies in medicine were uncommon in the past, but with the rising importance of financial considerations, it has become increasingly important to use available resources most efficiently.

PURPOSE

To analyze the current state of cost-effectiveness analyses in shoulder surgery.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic review of the current literature was performed following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. All full economic analyses published since January 1, 2010 and including the terms "cost analysis" and "shoulder" were checked for usability. The methodological quality of the studies was assessed using the Oxford Centre for Evidence-Based Medicine levels of evidence and established health economic criteria (Quality of Health Economic Studies [QHES] instrument).

RESULTS

A total of 34 studies fulfilled the inclusion criteria. Compared with older studies, recent studies were of better quality: one level 1 study and eight level 2 studies were included. The mean QHES score was 87 of 100. The thematic focus of most studies (n = 13) was rotator cuff tears, with the main findings as follows: (1) magnetic resonance imaging is a cost-effective imaging strategy, (2) primary (arthroscopic) rotator cuff repair (RCR) with conversion to reverse total shoulder arthroplasty in case of failure is the most cost-effective strategy, (3) the platelet-rich plasma augmentation of RCR seems not to be cost-effective, and (4) the cost-effectiveness of double-row RCR remains unclear. Other studies included shoulder instability (n = 3), glenohumeral osteoarthritis (n = 3), proximal humeral fractures (n = 4), subacromial impingement (n = 4), and other shoulder conditions (n = 7).

CONCLUSION

Compared with prior studies, the quality of recently available studies has improved significantly. Current studies could help decision makers to appropriately and adequately allocate resources. The optimal use of financial resources will be of increasing importance to improve medical care for patients. However, further studies are still necessary.

Beyond the clinical impact of aortic and pulmonary valve implantation: health-related quality of life, informal care and productivity†

OBJECTIVES

Our aim was to provide estimates of patient-reported health-related quality of life (HRQoL), use of informal care and productivity in patients after surgical aortic and pulmonary valve replacement and transcatheter aortic valve implantation.

METHODS

Consecutive cohorts of 1239 adult patients who had surgical aortic valve replacement or surgical pulmonary valve replacement and 433 patients who had transcatheter aortic valve implantation at 2 Dutch heart centres were cross-sectionally surveyed at a median time of 2.9 and 3.2 years after the intervention, respectively. The survey included questions on HRQoL (EQ-5D-5L and SF-12-v2), use of informal care and productivity in paid and unpaid work. All outcomes were compared with age and sex-matched individuals from the general population.

RESULTS

The response rate was 56% (n = 687) of patients who had surgical valve replacement and 59% (n = 257) of those who had transcatheter aortic valve implantation. Compared with the general population, patients reported poorer HRQoL on physical health domains, whereas their scores were comparable for mental health domains. After a heart valve implantation, patients reported using informal care more frequently than the general population, but labour participation was comparable. Patients with late complications [antibiotic treatment for endocarditis (n = 4), stroke (n = 11), transient ischaemic attack (n = 15)] reported lower HRQoL, greater use of informal care and greater productivity loss than patients without complications.

CONCLUSIONS

Patients who had aortic and pulmonary valve implantations experience relatively mild limitations in daily life compared to the general population. The consequences of a heart valve implantations beyond clinical outcomes should be considered to create realistic patient expectations of life after a heart valve implantation and unbiased resource allocation decisions at national levels.

Transcatheter aortic valve implantation economics: a grisly reality

Transcatheter aortic valve implantation (TAVI), an established treatment for inoperable and high-risk operable symptomatic patients with severe aortic stenosis with growing numbers of procedures and expanding indications, is an expensive therapy. Cost-effectiveness analyses rely on the value of the incremental cost-effectiveness ratio (ICER), which is the difference in cost between two possible interventions, divided by the difference in their effect. Several analyses have demonstrated that TAVI is cost-effective with an acceptable ICER for the inoperable patient alone and only via the iliofemoral route, while TAVI is more costly and is either less or equally effective as surgery in high-risk operable patients. When use of TAVI is extended to include a larger number of patients suitable for surgery, the overall results become less favorable. Acceptable ICERs should practically equate to the value of the gross domestic product (GDP) per capita in each country; however, the cost of the TAVI kit alone already exceeds the GDP per capita of all moderate- and low-income countries. An overview of the current cost-efficacy issues of TAVI is presented and this grisly reality is discussed, which may hopefully be improved in the future.