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Huang W, Wang Y, Luo Z, Zhang X, Yang M, Su J, Guo Y, Yu P. A Three-Day Prehabilitation Program is Cost-Effective for Preventing Pulmonary Complications after Heart Valve Surgery: A Health Economic Analysis of a Randomized Trial. Rev Cardiovasc Med 2024; 25:323. [PMID: 39355593 PMCID: PMC11440420 DOI: 10.31083/j.rcm2509323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 03/16/2024] [Accepted: 03/29/2024] [Indexed: 10/03/2024] Open
Abstract
Background While prehabilitation (pre surgical exercise) effectively prevents postoperative pulmonary complications (PPCs), its cost-effectiveness in valve heart disease (VHD) remains unexplored. This study aims to evaluate the cost-effectiveness of a three-day prehabilitation program for reducing PPCs and improving quality adjusted life years (QALYs) in Chinese VHD patients. Methods A cost-effectiveness analysis was conducted alongside a randomized controlled trial featuring concealed allocation, blinded evaluators, and an intention-to-treat analysis. In total, 165 patients scheduled for elective heart valve surgery at West China Hospital were randomized into intervention and control groups. The intervention group participated in a three-day prehabilitation exercise program supervised by a physiotherapist while the control group received only standard preoperative education. Postoperative hospital costs were audited through the Hospital Information System, and the EuroQol five-dimensional questionnaire was used to provide a 12-month estimation of QALY. Cost and effect differences were calculated through the bootstrapping method, with results presented in cost-effectiveness planes, alongside the associated cost-effectiveness acceptability curve (CEAC). All costs were denominated in Chinese Yuan (CNY) at an average exchange rate of 6.73 CNY per US dollar in 2022. Results There were no statistically significant differences in postoperative hospital costs (8484 versus 9615 CNY, 95% CI -2403 to 140) or in the estimated QALYs (0.909 versus 0.898, 95% CI -0.013 to 0.034) between the intervention and control groups. However, costs for antibiotics (339 versus 667 CNY, 95% CI -605 to -51), nursing (1021 versus 1200 CNY, 95% CI -330 to -28), and electrocardiograph monitoring (685 versus 929 CNY, 95% CI -421 to -67) were significantly lower in the intervention group than in the control group. The CEAC indicated that the prehabilitation program has a 92.6% and 93% probability of being cost-effective in preventing PPCs and improving QALYs without incurring additional costs. Conclusions While the three-day prehabilitation program did not significantly improve health-related quality of life, it led to a reduction in postoperative hospital resource utilization. Furthermore, it showed a high probability of being cost-effective in both preventing PPCs and improving QALYs in Chinese patients undergoing valve surgery. Clinical Registration Number This trial is registered in the Chinese Clinical Trial Registry (URL: https://www.chictr.org.cn/) with the registration identifier ChiCTR2000039671.
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Affiliation(s)
- Wei Huang
- Department of Rehabilitation Medicine, West China Hospital, Sichuan University, 610041 Chengdu, Sichuan, China
| | - Yuqiang Wang
- Department of Cardiac Surgery, West China Hospital, Sichuan University, 610041 Chengdu, Sichuan, China
| | - Zeruxin Luo
- Department of Rehabilitation Medicine, West China Hospital, Sichuan University, 610041 Chengdu, Sichuan, China
| | - Xiu Zhang
- Department of Rehabilitation Medicine, West China Hospital, Sichuan University, 610041 Chengdu, Sichuan, China
| | - Mengxuan Yang
- Department of Rehabilitation Medicine, West China Hospital, Sichuan University, 610041 Chengdu, Sichuan, China
| | - Jianhua Su
- Department of Rehabilitation Medicine, West China Hospital, Sichuan University, 610041 Chengdu, Sichuan, China
| | - Yingqiang Guo
- Department of Cardiac Surgery, West China Hospital, Sichuan University, 610041 Chengdu, Sichuan, China
| | - Pengming Yu
- Department of Rehabilitation Medicine, West China Hospital, Sichuan University, 610041 Chengdu, Sichuan, China
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Timmis A, Aboyans V, Vardas P, Townsend N, Torbica A, Kavousi M, Boriani G, Huculeci R, Kazakiewicz D, Scherr D, Karagiannidis E, Cvijic M, Kapłon-Cieślicka A, Ignatiuk B, Raatikainen P, De Smedt D, Wood A, Dudek D, Van Belle E, Weidinger F. European Society of Cardiology: the 2023 Atlas of Cardiovascular Disease Statistics. Eur Heart J 2024:ehae466. [PMID: 39189413 DOI: 10.1093/eurheartj/ehae466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 05/22/2024] [Accepted: 07/03/2024] [Indexed: 08/28/2024] Open
Abstract
This report from the European Society of Cardiology (ESC) Atlas Project updates and expands upon the 2021 report in presenting cardiovascular disease (CVD) statistics for the ESC member countries. This paper examines inequalities in cardiovascular healthcare and outcomes in ESC member countries utilizing mortality and risk factor data from the World Health Organization and the Global Burden of Disease study with additional economic data from the World Bank. Cardiovascular healthcare data were collected by questionnaire circulated to the national cardiac societies of ESC member countries. Statistics pertaining to 2022, or latest available year, are presented. New material in this report includes contemporary estimates of the economic burden of CVD and mortality statistics for a range of CVD phenotypes. CVD accounts for 11% of the EU's total healthcare expenditure. It remains the most common cause of death in ESC member countries with over 3 million deaths per year. Proportionately more deaths from CVD occur in middle-income compared with high-income countries in both females (53% vs. 34%) and males (46% vs. 30%). Between 1990 and 2021, median age-standardized mortality rates (ASMRs) for CVD decreased by median >50% in high-income ESC member countries but in middle-income countries the median decrease was <12%. These inequalities between middle- and high-income ESC member countries likely reflect heterogeneous exposures to a range of environmental, socioeconomic, and clinical risk factors. The 2023 survey suggests that treatment factors may also contribute with middle-income countries reporting lower rates per million of percutaneous coronary intervention (1355 vs. 2330), transcatheter aortic valve implantation (4.0 vs. 153.4) and pacemaker implantation (147.0 vs. 831.9) compared with high-income countries. The ESC Atlas 2023 report shows continuing inequalities in the epidemiology and management of CVD between middle-income and high-income ESC member countries. These inequalities are exemplified by the changes in CVD ASMRs during the last 30 years. In the high-income ESC member countries, ASMRs have been in steep decline during this period but in the middle-income countries declines have been very small. There is now an important need for targeted action to reduce the burden of CVD, particularly in those countries where the burden is greatest.
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Affiliation(s)
- Adam Timmis
- The William Harvey Research Institute, Queen Mary University London, London E1 4NS, UK
| | - Victor Aboyans
- Department of Cardiology, Dupuytren University Hospital, and EpiMaCT, Inserm 1098/IRD270, Limoges University, Limoges, France
| | - Panos Vardas
- Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, HHG, Athens, Greece
- European Society of Cardiology, European Heart Agency, European Heart Health Institute, Brussels, Belgium
| | - Nick Townsend
- Centre for Exercise, Nutrition and Health Sciences, School for Policy Studies, University of Bristol, Bristol BS8 1TZ, UK
| | - Aleksandra Torbica
- Centre for Research on Health and Social Care Management (CERGAS), Bocconi University, Milan, Italy
| | - Maryam Kavousi
- Department of Epidemiology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Radu Huculeci
- European Society of Cardiology, European Heart Agency, European Heart Health Institute, Brussels, Belgium
| | - Denis Kazakiewicz
- European Society of Cardiology, European Heart Agency, European Heart Health Institute, Brussels, Belgium
| | - Daniel Scherr
- Division of Cardiology, Medical University of Graz, Graz, Austria
| | - Efstratios Karagiannidis
- Second Department of Cardiology, General Hospital 'Hippokration', Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Marta Cvijic
- Department of Cardiology, University Medical Centre Ljubljana, and Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | | | - Barbara Ignatiuk
- Department of Cardiology, Humanitas Gavazzeni University Hospital, Bergamo, Italy
| | - Pekka Raatikainen
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
| | - Delphine De Smedt
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Angela Wood
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Dariusz Dudek
- Instytut Kardiologii, Uniwersytet Jagielloński, Collegium Medicum, Kraków, Poland
| | - Eric Van Belle
- Cardiologie, Institut cœur-poumon, CHU de Lille, Lille, France
| | - Franz Weidinger
- Department of Cardiology and Intensive Care Medicine, Landstrasse Clinic, Vienna, Austria
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Hyung K An J, Faridmoayer E, Haefner L, Salami AC, Sharath SE, Kougias P. Trends and predictors of inflation-adjusted costs in transcatheter and surgical aortic valve replacement in a nationally representative sample. Surgery 2024; 176:289-294. [PMID: 38772777 DOI: 10.1016/j.surg.2024.04.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 04/05/2024] [Accepted: 04/13/2024] [Indexed: 05/23/2024]
Abstract
BACKGROUND Transcatheter aortic valve replacement has become an accepted alternative to surgical aortic valve replacement. We examined the trends and predictors in inflation-adjusted costs of transcatheter aortic valve replacement and surgical aortic valve replacement. METHODS National Inpatient Sample identified patients who underwent aortic valve replacement for severe aortic stenosis by International Classification of Diseases, Ninth and Tenth Revisions, codes. Hospitalization costs were inflation-adjusted using the Federal Reserve's consumer price index to reflect current valuation. Outcomes of interest were unadjusted trend in annual cost for each procedure and predictors of in-patient cost. Generalized linear models with a log link function identified predictors of adjusted costs. Interaction terms determined where cost predictors were different by operation type. RESULTS Between 2011 and 2019, the mean annual inflation-adjusted cost of surgical aortic valve replacement increased from $62,853 to $63,743, in contrast to decreasing cost of transcatheter aortic valve replacement from $64,913 to $56,042 ($1,854 per year; P = .004). Significant independent predictors of patient-level cost included operation type (transcatheter aortic valve replacement associated with $9,625 increase; P < .001), incidence of in-hospital mortality ($28,836 increase; P < .001), elective status ($2,410 decrease; P < .001), Elixhauser Index ($995 increase; P < .001), and postoperative length of stay ($2,014 per day increase; P < .001). Compared to discharges with Medicare, discharges with private insurance and Medicaid paid $736 less (P = .004) and $1,863 less (P = .01), respectively. Increasing hospital volume was a significant predictor of decreasing patient level cost (P < .001). CONCLUSION Annual cost of transcatheter aortic valve replacement has decreased significantly and has been a more cost-effective modality compared to surgical aortic valve replacement since 2017. Predictors of patient-level costs allow for mindful preparation of healthcare systems for aortic valve replacement.
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Affiliation(s)
- Ju Hyung K An
- Department of Surgery, State University of New York, Downstate Health Sciences University, Brooklyn, NY. https://twitter.com/kja485
| | - Erfan Faridmoayer
- Department of Surgery, State University of New York, Downstate Health Sciences University, Brooklyn, NY. https://twitter.com/ErfanFarid
| | - Lindsay Haefner
- Department of Surgery, State University of New York, Downstate Health Sciences University, Brooklyn, NY
| | - Aitua C Salami
- Division of Cardiothoracic Surgery, Department of Surgery, University of Minnesota, Minneapolis, MN. https://twitter.com/ACSalami
| | - Sherene E Sharath
- Department of Surgery, State University of New York, Downstate Health Sciences University, Brooklyn, NY.
| | - Panos Kougias
- Department of Surgery, State University of New York, Downstate Health Sciences University, Brooklyn, NY. https://twitter.com/KougiasP
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Hou Y, Zhao J, Xu W, Chen L, Yang J, Wang Z, Si K. Genetic proxy of lipid-lowering drugs and calcific aortic valve stenosis: A Mendelian randomization study. Heliyon 2024; 10:e34089. [PMID: 39055828 PMCID: PMC11269895 DOI: 10.1016/j.heliyon.2024.e34089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 06/25/2024] [Accepted: 07/03/2024] [Indexed: 07/28/2024] Open
Abstract
Background Lipid metabolism plays an important role in the pathogenesis and development of calcific aortic valve stenosis. Our aim was to evaluate the causal effect of lipid-lowering drugs, such as low-density lipoprotein cholesterol (LDL-C) lowering and triglyceride lowering drugs, on the outcome of aortic valve stenosis using a two-sample Mendelian randomization (MR) study. Methods We used two genetic tools to represent the exposure of lipid-lowering drugs, including expression quantitative trait loci for the expression of drug target genes, and genetic variants within or near drug target genes that are associated with LDL-C and triglyceride concentrations from Genome-Wide Association Studies (GWAS). Effect estimates were calculated using summary-data-based MR (SMR) and inverse-variance-weighted MR (IVW-MR) analysis. Results Based on the results of SMR and IVW-MR analysis, LDL-C-lowering PCSK9 inhibitors have potential in reducing the risk of aortic valve stenosis (for SMR, OR: 1.044; 95%CI: 1.002-1.404; P = 0.047; for IVW-MR, OR: 1.647, 95%CI: 1.316-2.062, P < 0.001). However, no significant association was observed between triglyceride target gene expression, as well as triglyceride-lowering drugs, and aortic valve stenosis. Conclusion This two-sample drug-targeted MR study suggests a potential causal relationship between PCSK9 inhibitors and the reduction of calcific aortic valve stenosis risk.
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Affiliation(s)
- Yucheng Hou
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Jingwei Zhao
- Department of General Surgery, Xinhua Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine & Shanghai Key Laboratory of Biliary Tract Disease Research, Shanghai, China
| | - Wanchuang Xu
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
- Suzhou Medical College, Soochow University, Suzhou, China
| | - Lei Chen
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Jingyue Yang
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
- Suzhou Medical College, Soochow University, Suzhou, China
| | - Ziheng Wang
- MOE Frontier Science Centre for Precision Oncology, University of Macau, Macau SAR, China
- The School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Suzhou Industrial Park Monash Research Institute of Science and Technology, Suzhou, China
| | - Ke Si
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
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Amin S, Baron SJ, Galper BZ. Aortic valve replacement today: Outcomes, costs, and opportunities for improvement. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024; 64:78-86. [PMID: 38388246 DOI: 10.1016/j.carrev.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 01/19/2024] [Accepted: 02/07/2024] [Indexed: 02/24/2024]
Abstract
The introduction of transcatheter aortic valve replacement (TAVR) just two decades ago has transformed the treatment of severe symptomatic aortic stenosis. TAVR has not only extended the option of aortic valve replacement to patients deemed ineligible for surgery, it has also demonstrated similar or better short- and intermediate-term clinical outcomes compared with surgical aortic valve replacement (SAVR) in patients at all levels of surgical risk. These benefits have been achieved with similar or lower costs compared with SAVR, at least in the first 1-2 years for intermediate- and low-risk patients. Longer-term data will further inform clinical and shared decision-making. SUMMARY FOR ANNOTATED TABLE OF CONTENTS: In just over two decades, transcatheter aortic valve replacement has emerged as a frontline approach for appropriately selected patients with severe aortic stenosis. A growing body of evidence documents similar or better clinical outcomes and cost-effectiveness for transcatheter compared with surgical aortic valve replacement. Whether the mode is transcatheter or surgical, aortic valve replacement remains underutilized in patients with clear indications for intervention.
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Affiliation(s)
- Sameer Amin
- L.A. Care Health Plan, 1055 W. 7th St, 10th Floor, Los Angeles, CA 90017, United States
| | - Suzanne J Baron
- Interventional Cardiovascular Research, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, United States; Outcomes Research, Baim Institute for Clinical Research, 930 W. Commonwealth Ave., Boston, MA 02215, United States
| | - Benjamin Z Galper
- Structural Heart Disease Program, Mid-Atlantic Permanente Medical Group, 8008 Westpark Dr., McLean, VA 22102, United States; Cardiac Catheterization Laboratory, Virginia Hospital Center, 1701 N. George Mason Dr., Arlington, VA 22205, United States.
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6
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Hoagland A, Kipping S. Challenges in Promoting Health Equity and Reducing Disparities in Access Across New and Established Technologies. Can J Cardiol 2024; 40:1154-1167. [PMID: 38417572 DOI: 10.1016/j.cjca.2024.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 02/20/2024] [Accepted: 02/21/2024] [Indexed: 03/01/2024] Open
Abstract
Medical innovations and novel technologies stand to improve the return on high levels of health spending in developed countries, particularly in cardiovascular care. However, cardiac innovations also disrupt the landscape of accessing care, potentially creating disparities in who has access to novel and extant technologies. These disparities might disproportionately harm vulnerable groups, including those whose nonmedical conditions-including social determinants of health-inhibit timely access to diagnoses, referrals, and interventions. We first document the barriers to access novel and existing technologies in isolation, then proceed to document their interaction. Novel cardiac technologies might affect existing available services, and change the landscape of care for vulnerable patient groups who seek access to cardiology services. There is a clear need to identify and heed lessons learned from the dissemination of past innovations in the development, funding, and dissemination of future medical technologies to promote equitable access to cardiovascular care. We conclude by highlighting and synthesizing several policy implications from recent literature.
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Affiliation(s)
- Alex Hoagland
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Ontario Shores Centre for Mental Health Sciences, Toronto, Ontario, Canada.
| | - Sarah Kipping
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Ontario Shores Centre for Mental Health Sciences, Toronto, Ontario, Canada
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Benfari G, Essayagh B, Michelena HI, Ye Z, Inojosa JM, Ribichini FL, Crestanello J, Messika-Zeitoun D, Prendergast B, Wong BF, Thapa P, Enriquez-Sarano M. Severe aortic stenosis: secular trends of incidence and outcomes. Eur Heart J 2024; 45:1877-1886. [PMID: 38190428 DOI: 10.1093/eurheartj/ehad887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 11/17/2023] [Accepted: 12/21/2023] [Indexed: 01/10/2024] Open
Abstract
BACKGROUND AND AIMS Severe aortic stenosis (AS) is the guideline-based indication for aortic valve replacement (AVR), which has markedly increased with transcatheter approaches, suggesting possible increasing AS incidence. However, reported secular trends of AS incidence remain contradictory and lack quantitative Doppler echocardiographic ascertainment. METHODS All adults residents in Olmsted County (MN, USA) diagnosed over 20 years (1997-2016) with incident severe AS (first diagnosis) based on quantitatively defined measures (aortic valve area ≤ 1 cm2, aortic valve area index ≤ 0.6 cm2/m2, mean gradient ≥ 40 mmHg, peak velocity ≥ 4 m/s, Doppler velocity index ≤ 0.25) were counted to define trends in incidence, presentation, treatment, and outcome. RESULTS Incident severe AS was diagnosed in 1069 community residents. The incidence rate was 52.5 [49.4-55.8] per 100 000 patient-year, slightly higher in males vs. females and was almost unchanged after age and sex adjustment for the US population 53.8 [50.6-57.0] per 100 000 residents/year. Over 20 years, severe AS incidence remained stable (P = .2) but absolute burden of incident cases markedly increased (P = .0004) due to population growth. Incidence trend differed by sex, stable in men (incidence rate ratio 0.99, P = .7) but declining in women (incidence rate ratio 0.93, P = .02). Over the study, AS clinical characteristics remained remarkably stable and AVR performance grew and was more prompt (from 1.3 [0.1-3.3] years in 1997-2000 to 0.5 [0.2-2.1] years in 2013-16, P = .001) but undertreatment remained prominent (>40%). Early AVR was associated with survival benefit (adjusted hazard ratio 0.55 [0.42-0.71], P < .0001). Despite these improvements, overall mortality (3-month 8% and 3-year 36%), was swift, considerable and unabated (all P ≥ .4) throughout the study. CONCLUSIONS Over 20 years, the population incidence of severe AS remained stable with increased absolute case burden related to population growth. Despite stable severe AS presentation, AVR performance grew notably, but while declining, undertreatment remained substantial and disease lethality did not yet decline. These population-based findings have important implications for improving AS management pathways.
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Affiliation(s)
- Giovanni Benfari
- Department ofCardiovascular Disease, Mayo Clinic, Rochester, MN, USA
- Section of Cardiology, University of Verona, Verona, Italy
| | - Benjamin Essayagh
- Department ofCardiovascular Disease, Mayo Clinic, Rochester, MN, USA
- Department of Echocardiography, Cardio X Clinic, Cannes, France
| | | | - Zi Ye
- Department ofCardiovascular Disease, Mayo Clinic, Rochester, MN, USA
| | | | | | - Juan Crestanello
- Department ofCardiovascular Disease, Mayo Clinic, Rochester, MN, USA
| | - David Messika-Zeitoun
- Department of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Bernard Prendergast
- Department of Cardiology, Cleveland Clinic and Saint Thomas' Hospitals, London, UK
| | | | - Prabin Thapa
- Department ofCardiovascular Disease, Mayo Clinic, Rochester, MN, USA
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Ochakovski R, Zhang Y, Cerullo M. Hospital Characteristics Associated with Observed Transcatheter Aortic Valve Replacement Prices. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.05.20.24307421. [PMID: 38826203 PMCID: PMC11142259 DOI: 10.1101/2024.05.20.24307421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2024]
Abstract
Transcatheter aortic valve replacement (TAVR) has emerged as a revolutionary treatment for aortic stenosis. However, TAVR prices vary considerably, and factors associated with this variation remain unclear. We aim to describe the variation in TAVR prices in relation to hospital financial performance among institutions ranked by the U.S. News and World Report (USNWR). Using a modified two-part model, we examined financial and operational characteristics (TAVR performance scores, median all-payer within-hospital TAVR price, net hospital profit margin, hospital markups [i.e., charge-to-cost ratio], bed days available, and CMS wage index) of 640 TAVR-performing hospitals ranked by the USNWR. After determining observed to expected (O:E) ratios for TAVR prices for each hospital, we then examined hospital characteristics across O:E quintiles. Overall, price disclosure was 48.6% (n=311). Between the lowest and highest O:E quintiles, median hospital markup (4.75 vs 5.33; p=0.41) and median net hospital margin (1.76 vs 3.15; p=0.12) were comparable. The highest O:E ratio quintile had lower median TAVR prices compared to the lowest O:E ratio quintile ($72,129.12 vs $49,022.03; p<0.001). Most significantly, TAVR price IQR's within hospitals had a linear decline from the lowest to the highest O:E ratio quintiles ($119,043 vs $27,240; p<0.001). USNWR ranking scores had no significant variation across the quintiles (p=0.95). We concluded that hospitals that charge more than expected for TAVRs do not have higher profit margins nor markups and are not higher ranked by USNWR as those that charge less than expected. Additionally, with higher observed over expected TAVR prices, the variation in TAVR rates within hospitals decreased linearly. Finally, O:E TAVR price ratios appear to have no association with publicly reported hospital quality.
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Affiliation(s)
- Roni Ochakovski
- Duke University Trinity School of Arts and Sciences, Durham, North Carolina
| | - Yuqi Zhang
- Department of Surgery, Duke University, Durham, North Carolina
- Department of Surgery, Yale University, New Haven, Connecticut
- Margolis Center for Health Policy, Duke University, Durham, North Carolina
| | - Marcelo Cerullo
- Department of Surgery, Duke University, Durham, North Carolina
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Hoagland A, Kantarevic J, Stutely J, Wijeysundera HC. Importance of Direct Exposure in Continuing Medical Education: Primary Care Physician Learning Through Patients With Transcatheter Aortic Valve Implantation. Can J Cardiol 2024; 40:637-639. [PMID: 37995906 DOI: 10.1016/j.cjca.2023.11.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 10/31/2023] [Accepted: 11/17/2023] [Indexed: 11/25/2023] Open
Affiliation(s)
- Alex Hoagland
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.
| | - Jasmin Kantarevic
- Research and Analytics, Ontario Medical Association, Toronto, Ontario, Canada
| | - James Stutely
- Research and Analytics, Ontario Medical Association, Toronto, Ontario, Canada
| | - Harindra C Wijeysundera
- Department of Cardiology, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
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Amaki M, Moriwaki K, Nakai M, Yamano T, Okada A, Kanzaki H, Izumo M, Usuku H, Onishi T, Nagai T, Miyamoto Y, Fujita T, Kawai H, Akashi Y, Tsujita K, Matoba S, Kobayashi J, Izumi C, Anzai T. Cost-effective analysis of transcatheter aortic valve replacement in patients with severe symptomatic aortic stenosis: A prospective multicenter study. J Cardiol 2024; 83:169-176. [PMID: 37543193 DOI: 10.1016/j.jjcc.2023.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 07/25/2023] [Accepted: 07/28/2023] [Indexed: 08/07/2023]
Abstract
BACKGROUND Transcatheter aortic valve replacement (TAVR) for severe symptomatic aortic stenosis (AS) does not benefit all patients. We performed a prospective multicenter study to investigate the cost-effectiveness of TAVR in a Japanese cohort. METHODS AND RESULTS We prospectively enrolled 110 symptomatic patients with severe AS who underwent TAVR from five institutions. The quality of life measurement (QOL) was performed for each patient before and at 6 months after TAVR. Patients without an improvement in QOL at 6 months after TAVR were defined as non-responders. Pre-TAVR higher QOL, higher clinical frailty scale predicted the non-responders. Three models, 1) conservative treatment for all patients strategy, 2) TAVR for all patients strategy, and 3) TAVR for a selected patient strategy who is expected to be a responder, were simulated. Lifetime cost-effectiveness was estimated using incremental cost-effectiveness ratio (ICER) and cost per quality-adjusted life-year (QALY) gained. In comparison to conservative therapy for all patients, ICER was estimated to be 5,765,800 yen/QALY for TAVR for all patients and 2,342,175 yen/QALY for TAVR for selected patient strategy patients, which is less than the commonly accepted ICER threshold of 5,000,000 yen/QALY. CONCLUSIONS TAVR for selected patient strategy model is more cost-effective than TAVR for all patient strategy without reducing QOL in the Japanese healthcare system. TAVR for selected patient strategy has potential benefit for optimizing the TAVR treatment in patients with high frailty and may direct our resources toward beneficial interventions.
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Affiliation(s)
- Makoto Amaki
- Department of Heart Failure and Transplant, Division of Heart Failure, National Cerebral and Cardiovascular Center, Japan
| | - Kensuke Moriwaki
- Research Organization of Science and Technology, Ritsumeikan University, Japan
| | - Michikazu Nakai
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Japan
| | - Tetsuhiro Yamano
- Department of Cardiovascular Medicine, Kyoto Prefectural University of Medicine, Japan
| | - Atsushi Okada
- Department of Heart Failure and Transplant, Division of Heart Failure, National Cerebral and Cardiovascular Center, Japan
| | - Hideaki Kanzaki
- Department of Heart Failure and Transplant, Division of Heart Failure, National Cerebral and Cardiovascular Center, Japan
| | - Masaki Izumo
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, Japan
| | - Hiroki Usuku
- Department of Cardiovascular Medicine, Kumamoto University, Japan
| | - Tetsuari Onishi
- Department of Cardiology, Hyogo Prefectural Harima-Himeji General Medical Center, Japan
| | - Toshiyuki Nagai
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Japan
| | - Yoshihiro Miyamoto
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Japan
| | - Tomoyuki Fujita
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Japan
| | - Hiroya Kawai
- Department of Cardiology, Hyogo Prefectural Harima-Himeji General Medical Center, Japan
| | - Yoshihiro Akashi
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, Japan
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Kumamoto University, Japan
| | - Satoaki Matoba
- Department of Cardiovascular Medicine, Kyoto Prefectural University of Medicine, Japan
| | - Junjiro Kobayashi
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Japan
| | - Chisato Izumi
- Department of Heart Failure and Transplant, Division of Heart Failure, National Cerebral and Cardiovascular Center, Japan
| | - Toshihisa Anzai
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Japan.
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11
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Kermanshahchi J, Thind B, Davoodpour G, Hirsch M, Chen J, Reddy AJ, Yu Z, Falkenstein BE, Javidi D. Transcatheter Aortic Valve Replacement (TAVR) Versus Surgical Aortic Valve Replacement (SAVR): A Review on the Length of Stay, Cost, Comorbidities, and Procedural Complications. Cureus 2024; 16:e54435. [PMID: 38510891 PMCID: PMC10951673 DOI: 10.7759/cureus.54435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2024] [Indexed: 03/22/2024] Open
Abstract
This review provides an in-depth analysis of the effect of length of stay (LOS), comorbidities, and procedural complications on the cost-effectiveness of transcatheter aortic valve replacement (TAVR) in comparison to surgical aortic valve replacement (SAVR). We found that the average LOS was shorter for patients undergoing TAVR, contributing to lower average costs associated with the procedure, although the LOS varied between patients due to the severity of illness and comorbidities present. TAVR has also been found to improve the quality of life for patients receiving aortic valve replacement compared to SAVR. Although TAVR has a lower rate of most post-operative complications caused by SAVR, such as bleeding and cardiac complications, TAVR shows an increased rate of permanent pacemaker (PPM) implantation due to mechanical trauma on the heart's conduction system. In addition, our findings suggest that the cost-effectiveness of each procedure varies based on the types of valve, the patient history of other medical conditions, and the procedural methods. Our findings show that TAVR is preferred over SAVR in terms of cost-effectiveness across a variety of patients with other coexisting medical conditions, including cancer, advanced kidney disease, cirrhosis, diabetes mellitus, and bundle branch block. TAVR also appears to be superior to SAVR with fewer post-operative complications. However, TAVR appears to have a higher rate of PPM implantation rates as compared to SAVR. The comorbidities of the valve recipient must be considered when deciding whether to use TAVR or SAVR as cost-effectiveness varies with the patient background.
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Affiliation(s)
| | - Birpartap Thind
- Medicine, California University of Science and Medicine, Colton, USA
| | | | - Megan Hirsch
- Medicine, California University of Science and Medicine, Colton, USA
| | - Jeff Chen
- Medicine, California University of Science and Medicine, Colton, USA
| | - Akshay J Reddy
- Medicine, California University of Science and Medicine, Colton, USA
| | - Zeyu Yu
- College of Medicine, California Health Sciences University, Clovis, USA
| | | | - Daryoush Javidi
- Medical Education, California University of Science and Medicine, Colton, USA
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12
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Kobayashi J, Baron SJ, Takagi K, Thompson CA, Jiao X, Yamabe K. Cost-effectiveness analysis of transcatheter aortic valve implantation in aortic stenosis patients at low- and intermediate-surgical risk in Japan. J Med Econ 2024; 27:697-707. [PMID: 38654415 DOI: 10.1080/13696998.2024.2346397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 04/19/2024] [Indexed: 04/26/2024]
Abstract
OBJECTIVE To analyze the cost-effectiveness of transcatheter aortic valve implantation (TAVI) using the SAPIEN 3 (Edwards Lifesciences, Irvine, CA) compared to surgical aortic valve replacement (SAVR) in low- and intermediate-risk patients from a Japanese public healthcare payer perspective. METHODS A Markov model cost-effectiveness analysis was developed. Clinical and utility data were extracted from a systematic literature review. Cost inputs were obtained from analysis of the Medical Data Vision claims database and supplemented with a targeted literature search. The robustness of the results was assessed using sensitivity analyses. Scenario analyses were performed to determine the impact of lower mean age (77.5 years) and the effect of two different long-term mortality hazard ratios (TAVI versus SAVR: 0.9-1.09) on both risk-level populations. This analysis was conducted according to the guidelines for cost-effectiveness evaluation in Japan from Core 2 Health. RESULTS In intermediate-risk patients, TAVI was a dominant procedure (TAVI had lower cost and higher effectiveness). In low-risk patients, the incremental cost effectiveness ratio (ICER) for TAVI was ¥750,417/quality-adjusted-life-years (QALY), which was below the cost-effectiveness threshold of ¥5 million/QALY. The ICER for TAVI was robust to all tested sensitivity and scenario analyses. CONCLUSIONS TAVI was dominant and cost-effective compared to SAVR in intermediate- and low-risk patients, respectively. These results suggest that TAVI can provide meaningful value to Japanese patients relative to SAVR, at a reasonable incremental cost for patients at low surgical risk and potentially resulting in cost-savings in patients at intermediate surgical risk.
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Affiliation(s)
- Junjiro Kobayashi
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Suzanne J Baron
- Interventional Cardiology, Massachusetts General Hospital, Boston, MA, USA
- BAIM Institute for Clinical Research, Boston, MA, USA
| | - Kensuke Takagi
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Christin A Thompson
- Global Health Economics & Reimbursement, Edwards Lifesciences, Irvine, CA, USA
| | - Xiayu Jiao
- Global Health Economics & Reimbursement, Edwards Lifesciences, Irvine, CA, USA
| | - Kaoru Yamabe
- Market Access, Edwards Lifesciences, Tokyo, Japan
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13
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Cormican DS. The Economic Impact of Transcatheter Aortic Valve Replacement in Low-Surgical-Risk Patients Over 2 Years: The Start of the Conversation, Not the Final Word. J Cardiothorac Vasc Anesth 2023; 37:2425-2427. [PMID: 37709609 DOI: 10.1053/j.jvca.2023.08.127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 08/09/2023] [Indexed: 09/16/2023]
Affiliation(s)
- Daniel S Cormican
- Division of Cardiothoracic Anesthesiology, Division of Surgical Critical Care, Anesthesiology Institute, Allegheny Health Network, Pittsburgh, PA
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14
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Reynolds MR, Stein AB, Sun X, Hytopoulos E, Steinhubl SR, Cohen DJ. Cost-Effectiveness of AF Screening With 2-Week Patch Monitors: The mSToPS Study. Circ Cardiovasc Qual Outcomes 2023; 16:e009751. [PMID: 37905421 PMCID: PMC10659247 DOI: 10.1161/circoutcomes.122.009751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 08/07/2023] [Indexed: 11/02/2023]
Abstract
BACKGROUND The mSToPS study (mHealth Screening to Prevent Strokes) reported screening older Americans at risk for atrial fibrillation (AF) and stroke using 2-week patch monitors was associated with increased rates of AF diagnosis and anticoagulant prescription within 1 year and improved clinical outcomes at 3 years relative to matched controls. Cost-effectiveness of this AF screening approach has not been explored. METHODS We conducted a US-based health economic analysis of AF screening using patient-level data from mSToPS. Clinical outcomes, resource use, and costs were obtained through 3 years using claims data. Individual costs, survival, and quality-adjusted life years (QALYs) were projected over a lifetime horizon using regression modeling, US life tables, and external data where needed. Adjustment between groups was performed using propensity score bin bootstrapping. RESULTS Screening participants (mean age, 74 years, 41% female, median CHA2DS2-VASC score 3) wore on average 1.7 two-week monitors at a mean cost of $614/person. Over 3 years, outpatient visits were more frequent for monitored than unmonitored individuals (difference 190 per 100 patient-years [95% CI, 82-298]), but emergency department visits (-8.3 [95% CI, -12.6 to -4.1]) and hospitalizations (-15.2 [CI, -22 to -8.6]) were less frequent. Total adjusted 3-year costs were slightly higher (mean difference, $1551 [95% CI, -$1047 to $4038]) in the monitoring group. In patient-level projections, the monitoring group had slightly greater quality-adjusted survival (8.81 versus 8.71 QALYs, difference, 0.09 [95% CI, -0.05 to 0.24]) and slightly higher lifetime costs, resulting in an incremental cost-effectiveness ratio of $36 100/QALY gained. With bootstrap resampling, the incremental cost-effectiveness ratio for monitoring was <$50 000/QALY in 64% of study replicates, and <$150 000/QALY in 91%. CONCLUSIONS Using lifetime projections derived from the mSToPS study, we found that AF screening using 2-week patch monitors in older Americans was associated with high economic value. Confirmation of these uncertain findings in a randomized trial is warranted. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT02506244.
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Affiliation(s)
- Matthew R. Reynolds
- Division of Cardiology, Lahey Hospital and Medical Center, Burlington, MA (M.R.R.)
| | | | - Xiaowu Sun
- CVS Health, Woonsocket, RI (A.B.S., X.S.)
| | | | | | - David J. Cohen
- Cardiovascular Research Foundation, New York, NY (D.J.C.)
- St. Francis Hospital and Heart Center, Roslyn, New York, NY (D.J.C.)
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15
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D'Errigo P, Marcellusi A, Biancari F, Barbanti M, Cerza F, Tarantini G, Ranucci M, Ussia GP, Costa G, Badoni G, Fraccaro C, Meucci F, Baglio G, Seccareccia F, Tamburino C, Rosato S. Financial Burden of Transcatheter Aortic Valve Implantation. Am J Cardiol 2023; 203:1-8. [PMID: 37478636 DOI: 10.1016/j.amjcard.2023.06.088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 06/11/2023] [Accepted: 06/16/2023] [Indexed: 07/23/2023]
Abstract
Given the increasing population eligible for transcatheter aortic valve implantation (TAVI), resource utilization has become an important focus in this setting. We aimed to estimate the change in the financial burden of TAVI therapy over 2 different periods. A probabilistic Markov model was developed to estimate the cost consequences of increased center experience and the introduction of newer-generation TAVI devices compared with an earlier TAVI period in a cohort of 6,000 patients. The transition probabilities and hospitalization costs were retrieved from the OBSERVANT (Observational Study of Effectiveness of AVR-TAVI procedures for severe Aortic steNosis Treatment) and OBSERVANT II (Observational Study of Effectiveness of TAVI with new generation deVices for severe Aortic stenosis Treatment) studies, including 1,898 patients treated with old-generation devices and 1,417 patients treated with new-generation devices. The propensity score matching resulted in 853 pairs, with well-balanced baseline risk factors. The mean EuroSCORE II (6.6% vs 6.8%, p = 0.76) and the mean age (82.0 vs 82.1 y, p = 0.62) of the early TAVI period and new TAVI period were comparable. The new TAVI period was associated with a significant reduction in rehospitalizations (-30.5% reintervention, -25.2% rehospitalization for major events, and -30.8% rehospitalization for minor events) and a 20% reduction in 1-year mortality. These reductions resulted in significant cost savings over a 1-year period (-€4.1 million in terms of direct costs and -€19.7 million considering the additional cost of the devices). The main cost reduction was estimated for rehospitalization, accounting for 79% of the overall cost reduction (not considering the costs of the devices). In conclusion, the introduction of new-generation TAVI devices, along with increased center experience, led to significant cost savings at 1-year compared with an earlier TAVI period, mainly because of the reduction in rehospitalization costs.
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Affiliation(s)
- Paola D'Errigo
- National Center for Global Health, Istituto Superiore di Sanità, Rome, Italy
| | - Andrea Marcellusi
- Economic Evaluation and HTA (EEHTA-CEIS), Faculty of Economics, University of Rome "Tor Vergata", Rome, Italy
| | - Fausto Biancari
- Clinica Montevergine, GVM Care & Research, Mercogliano, Italy; Heart and Lung Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | | | - Francesco Cerza
- Italian National Agency for Regional Healthcare Services, Rome, Italy
| | - Giuseppe Tarantini
- Division of Cardiology, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Marco Ranucci
- Department of Cardiothoracic and Vascular Anesthesia and ICU, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | | | | | - Gabriella Badoni
- National Center for Global Health, Istituto Superiore di Sanità, Rome, Italy
| | - Chiara Fraccaro
- Division of Cardiology, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | | | - Giovanni Baglio
- Italian National Agency for Regional Healthcare Services, Rome, Italy
| | - Fulvia Seccareccia
- National Center for Global Health, Istituto Superiore di Sanità, Rome, Italy
| | - Corrado Tamburino
- A.O.U. Policlinico "G. Rodolico - San Marco", University of Catania, Catania, Italy
| | - Stefano Rosato
- National Center for Global Health, Istituto Superiore di Sanità, Rome, Italy
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16
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Varghese SS, Hetu MF, Bowman M, Herr J, Al-Turki M, Jaff Z, James P, Malik P, Payne D, Johri AM. Impact of transcatheter aortic valve implantation on circulating von Willebrand factor in patients with severe aortic stenosis. Haemophilia 2023; 29:1306-1312. [PMID: 37428626 DOI: 10.1111/hae.14825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 05/25/2023] [Accepted: 06/28/2023] [Indexed: 07/12/2023]
Abstract
INTRODUCTION Severe aortic stenosis (AS) can lead to degradation of high molecular weight (HMW) von Willebrand factor (VWF) which can result in haemostatic abnormalities. While studies have explored changes in VWF profiles before and after surgical aortic valve replacement (SAVR), the longer-term changes in VWF profiles pre- and post-transcatheter aortic valve implantation (TAVI) are less understood. AIM Our primary objective was to identify differences in VWF multimer profiles and VWF function pre-TAVI and 1-month post-TAVI. Our secondary objective was to correlate VWF markers with measures of AS severity. METHODS Adult patients with severe AS referred for TAVI at our institution were prospectively enrolled in this cohort study. Blood samples were collected for plasma analysis at three time points for all patients: 1 day pre-TAVI, 3 days post-TAVI, and 1-month post-TAVI. VWF antigen, activity, propeptide, collagen binding, multimers, and factor VIII coagulant activity were determined at each time point. Correlations between VWF parameters and severity of AS were assessed. RESULTS Twenty participants (15 males, five females) with severe AS were recruited for the study. There was a significant increase in HMW VWF between pre-procedure and 1-month post-TAVI (p < .05). There was a transient increase in VWF antigen levels and activity at 3-days post TAVI that decreased to pre-TAVI levels at 1-month. There were no statistically significant correlations between VWF markers and AS severity. CONCLUSIONS This is the first study to elucidate longer-term (>1 week) improvements in HMW VWF after a TAVI procedure in severe AS patients.
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Affiliation(s)
- Sonu S Varghese
- Department of Medicine, Queen's University, Kingston, ON, Canada
| | | | - Mackenzie Bowman
- Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Julia Herr
- Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Mohamed Al-Turki
- Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Zardasht Jaff
- Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Paula James
- Department of Medicine, Queen's University, Kingston, ON, Canada
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, ON, Canada
| | - Paul Malik
- Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Darrin Payne
- Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Amer M Johri
- Department of Medicine, Queen's University, Kingston, ON, Canada
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, ON, Canada
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17
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Zamorano JL, Appleby C, Benamer H, Frankenstein L, Musumeci G, Nombela-Franco L. Improving access to transcatheter aortic valve implantation across Europe by restructuring cardiovascular services: An expert council consensus statement. Catheter Cardiovasc Interv 2023; 102:547-557. [PMID: 37431253 DOI: 10.1002/ccd.30760] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 06/01/2023] [Accepted: 06/28/2023] [Indexed: 07/12/2023]
Abstract
Transcatheter aortic valve implantation (TAVI) is recommended for a growing range of patients with severe aortic stenosis in the European Society of Cardiology and European Association for Cardio-Thoracic Surgery (ESC/EACTS) 2021 Guidelines update. However, guideline implementation programs are needed to ensure the application of clinical recommendations which will favorably influence disease outcomes. An Expert Council was convened to identify whether cardiology services across Europe are set up to address the growing needs of patients with severe aortic stenosis for increased access to TAVI by identifying the key challenges faced in growing TAVI programs and mapping associated solutions. Wide variation exists across Europe in terms of TAVI availability and capacity to deliver the increased demand for TAVI in different countries. The recommendations of this Expert Council focus on the short-to-medium-term aspects where the most immediate, actionable impact can be achieved. The focus on improving procedural efficiency and optimizing the patient pathway via clinical practice and patient management demonstrates how to mitigate the current major issues of shortfall in catheterization laboratory, workforce, and bed capacity. Procedural efficiencies may be achieved through steps including streamlined patient assessment, the benchmarking of standards for minimalist procedures, standardized approaches around patient monitoring and conduction issues, and the implementation of nurse specialists and dedicated TAVI coordinators to manage organization, logistics, and early mobilization. Increased collaboration with wider stakeholders within institutions will support successful TAVI uptake and improve patient and economic outcomes. Further, increased education, collaboration, and partnership between cardiology centers will facilitate sharing of expertise and best clinical practice.
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Affiliation(s)
- José Luis Zamorano
- Department of Cardiology, University Hospital Ramon y Cajal, Madrid, Spain
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18
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Lauck SB, Yu M, Pu A, Virani S, Meier D, Akodad M, Sathananthan J, Chan AW, Price J, Wong D, Wood DA, Webb JG, Abel JG. Temporal Changes in Quality Indicators in a Regional System of Care After Surgical and Transcatheter Aortic Valve Replacement. CJC Open 2023; 5:508-521. [PMID: 37496781 PMCID: PMC10366640 DOI: 10.1016/j.cjco.2023.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 03/27/2023] [Indexed: 07/28/2023] Open
Abstract
Background Historically, quality-of-care monitoring was performed separately for transcatheter and surgical aortic valve replacement (TAVR, SAVR). Using consensus indicators, we provide a global report on the quality of care for treatment of aortic stenosis across the highest-volume treatments: transfemoral (TF) TAVR, isolated SAVR, and SAVR combined with coronary artery bypass graft. Methods Retrospective observational cohort study of consecutive patients in a regional system of care. Primary endpoint was 30-day and 1-year mortality (2015-2019). Secondary endpoints included rate of new pacemaker, rate of readmission, and length of stay (2012-2019). Following multivariable logistic regressions, we developed mortality case-mix adjustment models to report risk estimates. Results The proportion of patients receiving TAVR grew from 32% to 53% (2015-2019). Those receiving TF TAVR were significantly older, with higher rates of comorbidities. Observed 30-day and 1-year all-cause mortality after TF TAVR decreased from 3.1% to 0.6% (P = 0.03), and 13.6% to 6.6% (P = 0.09), respectively; surgical mortality rates for isolated SAVR and SAVR combined with coronary artery bypass graft were low and did not change significantly over time, ranging from 0.3% to 1.4% and from 0.9% to 3.4%, respectively at 30 days, and from 0.9% to 3.4% and from 4.7% to 6.7 at 1 year. In the TF TAVR cohort, the observed vs expected ratio for 30-day and 1-year mortality decreased significantly from 1.9 (95% confidence interval [CI] 0.9, 3.5) to 0.3 (95% CI 0.1, 0.8), and from 1.3 (95% CI 0.9, 1.7) to 0.7 (95% CI 0.5, 0.99), respectively; no change occurred in risk-adjusted surgical mortality. Conclusions Consensus quality indicators provide unique insights on the quality of care for patients receiving treatment for aortic stenosis.
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Affiliation(s)
- Sandra B. Lauck
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Maggie Yu
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Aihua Pu
- Cardiac Services BC, Vancouver, British Columbia, Canada
| | - Sean Virani
- Cardiac Services BC, Vancouver, British Columbia, Canada
| | - David Meier
- Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mariam Akodad
- Institut Cardiovasculaire Paris Sud, Hôpital Privé Jacques-Cartier, Ramsay Santé, Massy, France
| | - Janarthanan Sathananthan
- University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Albert W. Chan
- Division of Cardiology, Royal Columbian Hospital, New Westminster, British Columbia, Canada
| | - Joel Price
- Division of Cardiovascular and Thoracic Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Daniel Wong
- Department of Cardiac Surgery, Royal Columbian Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - David A. Wood
- University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - John G. Webb
- University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - James G. Abel
- University of British Columbia, Vancouver, British Columbia, Canada
- Division of Cardiovascular and Thoracic Surgery, University of British Columbia, Vancouver, British Columbia, Canada
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19
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Heathcote L, Srivastava T, Sarmah A, Kearns B, Sutton A, Candolfi P. A Systematic Review and Statistical Analysis of Factors Influencing the Cost-Effectiveness of Transcatheter Aortic Valve Implantation for Symptomatic Severe Aortic Stenosis. CLINICOECONOMICS AND OUTCOMES RESEARCH 2023; 15:459-475. [PMID: 37337594 PMCID: PMC10277006 DOI: 10.2147/ceor.s392566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 05/15/2023] [Indexed: 06/21/2023] Open
Abstract
Objective Transcatheter aortic valve implantation (TAVI) is a disruptive technology recommended for patients with symptomatic severe aortic stenosis (sSAS). Despite being available for over 15 years in Europe, with an extensive volume of clinical and economic evaluations across all surgical risk groups, there is little evidence on the identification of the key drivers of TAVI's cost-effectiveness. This study sought to identify these factors and quantify their role. Methods A systematic literature review was conducted to identify published economic evaluations of TAVI. This was supplemented by health technology assessment reports. The primary outcome was the likelihood of TAVI being found cost-effective. Secondary outcomes of TAVI being dominant, and the incremental health benefits of TAVI were also explored. Results Forty-two studies, reporting 65 unique analyses, were identified. TAVI was found to be cost-effective and dominant in 74% and 20% of analyses, respectively. The latest generation balloon-expandable TAVI device (SAPIEN 3) was more likely to be found cost-effective, as was TAVI use in low-risk populations and when performed via transfemoral access route. There was heterogeneity in the approach taken to economic modelling, which may also influence estimates of cost-effectiveness. Analyses that found TAVI to be dominant always compared it to surgery and usually considered the latest generation balloon-expandable TAVI device. Largest health benefits were observed for the inoperable risk group. Conclusion For patients with sSAS, TAVI is typically a cost-effective treatment option. There are important differences by device generation, risk group and access route. It is crucial to consider these differences when appraising the health economic evidence-base for TAVI.
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Affiliation(s)
- Laura Heathcote
- School for Health and Related Research, the University of Sheffield, Sheffield, UK
| | - Tushar Srivastava
- School for Health and Related Research, the University of Sheffield, Sheffield, UK
| | | | - Ben Kearns
- School for Health and Related Research, the University of Sheffield, Sheffield, UK
| | - Anthea Sutton
- School for Health and Related Research, the University of Sheffield, Sheffield, UK
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20
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Galper BZ, Chinnakondepalli KM, Wang K, Magnuson EA, Lu M, Thourani VH, Kodali S, Makkar R, Herrmann HC, Kapadia S, Williams M, Webb J, Smith CR, Mack MJ, Leon MB, Cohen DJ. Economic Outcomes of Transcatheter Versus Surgical Aortic Valve Replacement in Patients with Severe Aortic Stenosis and Low Surgical Risk: Results from the PARTNER 3 Trial. Circulation 2023; 147:1594-1605. [PMID: 37154049 DOI: 10.1161/circulationaha.122.062481] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 03/08/2023] [Indexed: 05/10/2023]
Abstract
BACKGROUND In patients with severe symptomatic aortic stenosis at low surgical risk, transfemoral transcatheter aortic valve replacement (TAVR) with the SAPIEN 3 valve has been shown to reduce the composite of death, stroke, or rehospitalization at 2-year follow-up compared with surgical aortic valve replacement (SAVR). Whether TAVR is cost-effective compared with SAVR for low-risk patients remains uncertain. METHODS Between 2016 and 2017, 1000 low-risk patients with aortic stenosis were randomly assigned to TAVR with the SAPIEN 3 valve or SAVR in the PARTNER 3 trial (Placement of Aortic Transcatheter Valves). Of these patients, 929 underwent valve replacement, were enrolled in the United States, and were included in the economic substudy. Procedural costs were estimated using measured resource use. Other costs were determined by linkage with Medicare claims or by regression models when linkage was not feasible. Health utilities were estimated using the EuroQOL 5-item questionnaire. With the use of a Markov model informed by in-trial data, lifetime cost-effectiveness from the perspective of the US health care system was estimated in terms of cost per quality-adjusted life-year gained. RESULTS Although procedural costs were nearly $19 000 higher with TAVR, total index hospitalization costs were only $591 more with TAVR compared with SAVR. Follow-up costs were lower with TAVR such that TAVR led to 2-year cost savings of $2030/patient compared with SAVR (95% CI, -$6222 to $1816) and a gain of 0.05 quality-adjusted life-years (95% CI, -0.003 to 0.102). In our base-case analysis, TAVR was projected to be an economically dominant strategy with a 95% probability that the incremental cost-effectiveness ratio for TAVR would be <$50 000/quality-adjusted life-year gained (consistent with high economic value from a US health care perspective). These findings were sensitive to differences in long-term survival, however, such that a modest long-term survival advantage with SAVR would render SAVR cost-effective (although not cost saving) compared with TAVR. CONCLUSIONS For patients with severe aortic stenosis and low surgical risk similar to those enrolled in the PARTNER 3 trial, transfemoral TAVR with the SAPIEN 3 valve is cost saving compared with SAVR at 2 years and is projected to be economically attractive in the long run as long as there are no substantial differences in late death between the 2 strategies. Long-term follow-up will be critical to ultimately determine the preferred treatment strategy for low-risk patients from both a clinical and economic perspective.
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Affiliation(s)
| | | | - Kaijun Wang
- Saint-Luke's Mid America Heart Institute, Kansas City, MO (K.M.C., K.W., E.A.M.)
| | - Elizabeth A Magnuson
- Saint-Luke's Mid America Heart Institute, Kansas City, MO (K.M.C., K.W., E.A.M.)
| | | | | | - Susheel Kodali
- New York-Presbyterian/Columbia University Irving Medical Center, New York (S. Kodali, C.R.S., M.B.L.)
| | - Raj Makkar
- Cedars-Sinai Medical Center, Los Angeles, CA (R.M.)
| | | | | | | | - John Webb
- St. Paul's Hospital, Vancouver, BC, Canada (J.W.)
| | - Craig R Smith
- New York-Presbyterian/Columbia University Irving Medical Center, New York (S. Kodali, C.R.S., M.B.L.)
| | | | - Martin B Leon
- New York-Presbyterian/Columbia University Irving Medical Center, New York (S. Kodali, C.R.S., M.B.L.)
- Cardiovascular Research Foundation, New York, NY (M.B.L., D.J.C.)
| | - David J Cohen
- Cardiovascular Research Foundation, New York, NY (M.B.L., D.J.C.)
- St. Francis Hospital, Roslyn, NY (D.J.C.)
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21
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Mubashir T, Zaki J, Yeong An S, Salas De Armas IA, Liang Y, Markham T, Feng H, Akay MH, Nascimbene A, Akkanti B, Williams GW, Zasso F, Aponte MP, Gregoric ID, Kar B. Does the Type of Chronic Heart Failure Impact In-Hospital Outcomes for Aortic Valve Replacement Procedures? Tex Heart Inst J 2023; 50:493363. [PMID: 37270296 DOI: 10.14503/thij-21-7775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
BACKGROUND This study assessed in-hospital outcomes of patients with chronic systolic, diastolic, or mixed heart failure (HF) undergoing transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR). METHODS The Nationwide Inpatient Sample database was used to identify patients with aortic stenosis and chronic HF who underwent TAVR or SAVR between 2012 and 2015. Propensity score matching and multivariate logistic regression were used to determine outcome risk. RESULTS A cohort of 9,879 patients with systolic (27.2%), diastolic (52.2%), and mixed (20.6%) chronic HF were included. No statistically significant differences in hospital mortality were noted. Overall, patients with diastolic HF had the shortest hospital stays and lowest costs. Compared with patients with diastolic HF, the risk of acute myocardial infarction (TAVR odds ratio [OR], 1.95; 95% CI, 1.20-3.19; P = .008; SAVR OR, 1.38; 95% CI, 0.98-1.95; P = .067) and cardiogenic shock (TAVR OR, 2.15; 95% CI, 1.43-3.23; P < .001; SAVR OR, 1.89; 95% CI, 1.42-2.53; P ≤ .001) was higher in patients with systolic HF, whereas the risk of permanent pacemaker implantation (TAVR OR, 0.58; 95% CI, 0.45-0.76; P < .001; SAVR OR, 0.58; 95% CI, 0.40-0.84; P = .004) was lower following aortic valve procedures. In TAVR, the risk of acute deep vein thrombosis and kidney injury was higher, although not statistically significant, in patients with systolic HF than in those with diastolic HF. CONCLUSION These outcomes suggest that chronic HF types do not incur statistically significant hospital mortality risk in patients undergoing TAVR or SAVR.
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Affiliation(s)
- Talha Mubashir
- Department of Anesthesiology, The University of Texas Health Science Center at Houston, Houston, Texas
| | - John Zaki
- Department of Anesthesiology, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Sin Yeong An
- Department of Anesthesiology, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Ismael A Salas De Armas
- Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Yafen Liang
- Department of Anesthesiology, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Travis Markham
- Department of Anesthesiology, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Han Feng
- Tulane University School of Medicine, New Orleans, Louisiana
| | - Mehmet H Akay
- Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Angelo Nascimbene
- Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Bindu Akkanti
- Department of Pulmonary, Critical Care and Sleep Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas
| | - George W Williams
- Department of Anesthesiology, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Fabricio Zasso
- Department of Anesthesiology and Pain Medicine, Mount Sinai Hospital-Sinai Health System, University of Toronto, Toronto, Canada
| | - Maria Patarroyo Aponte
- Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Igor D Gregoric
- Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Biswajit Kar
- Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Center at Houston, Houston, Texas
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22
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Chotnoppharatphatthara P, Yoodee V, Taesotikul S, Yadee J, Permsuwan U. Transcatheter aortic valve implantation in patients with severe symptomatic aortic valve stenosis: systematic review of cost-effectiveness analysis. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2023; 24:359-376. [PMID: 35708785 DOI: 10.1007/s10198-022-01477-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 05/10/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Transcatheter aortic valve implantation (TAVI) is a less invasive and costly treatment for patients with severe aortic stenosis (AS). This study aimed to systematically review the published literature focusing on economic evaluation of TAVI compared with other alternative treatments in AS populations. METHODS A systematic review was conducted from inception until May 2021 using PubMed, Scopus, Web of science and Embase databases. The qualities of included studies were evaluated using Consolidated Health Economic Evaluation Reporting Standard (CHEERS) criteria. Data of costs, outcomes, incremental cost-effectiveness ratio (ICER) and willingness to pay were extracted. To compare results, ICERs were converted to the 2020 United States dollar (USD) rate. RESULTS Of the 29 included cost-effectiveness studies, TAVI was cost-effective in all studies in the low-risk group (3/3), 77% of studies (7/9) in the intermediate-risk group, half of the studies (6/12) in the high-risk group, and 83% of studies (10/12) in the inoperable group. When adjusted to USD 2020, ICERs ranged from USD 2741 to 1027,674 USD per quality-adjusted life-year gained. The overall quality of the studies ranged from moderate to high. CONCLUSIONS TAVI is potentially a cost-effective alternative to surgical aortic valve replacement (SAVR) for patients with operable AS with low, intermediate or high risk compared with medical management (MM) for patients with inoperable AS. TAVI was associated with a significant gain in quality-adjusted life-years in almost all studies compared to either SAVR or MM. TAVI is a costly procedure; therefore, justifying its cost-effectiveness depends on the acceptable threshold in each country.
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Affiliation(s)
| | - Voratima Yoodee
- Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, 50200, Thailand
- Pharmaceutical Care Training Center (PCTC), Faculty of Pharmacy, Chiang Mai University, Chiang Mai, 50200, Thailand
| | - Suthinee Taesotikul
- Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, 50200, Thailand
- Pharmaceutical Care Training Center (PCTC), Faculty of Pharmacy, Chiang Mai University, Chiang Mai, 50200, Thailand
| | - Jirawit Yadee
- Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, 50200, Thailand
- Center for Medical and Health Technology Assessment (CM-HTA), Faculty of Pharmacy, Chiang Mai University, Chiang Mai, 50200, Thailand
| | - Unchalee Permsuwan
- Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, 50200, Thailand.
- Center for Medical and Health Technology Assessment (CM-HTA), Faculty of Pharmacy, Chiang Mai University, Chiang Mai, 50200, Thailand.
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23
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Petrou P. The economics of TAVI: A systematic review. IJC HEART & VASCULATURE 2023; 44:101173. [PMID: 36747880 PMCID: PMC9898648 DOI: 10.1016/j.ijcha.2023.101173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 12/28/2022] [Accepted: 01/05/2023] [Indexed: 01/27/2023]
Abstract
Objective The scope of this systematic review is to update the existing body of evidence regarding the cost-effectiveness of transcatheter aortic valve implantation, stratified across all risk categories, and to assess their methodological quality. Methods A systematic review was performed including published cost-effectiveness analyses of heart valve implantations. The quality was assessed with the Quality of Health Economics Tool. Results We identified 33 economic evaluations of transcatheter aortic heart valve implantations. Results were not consistent, ranging from dominant to dominating. Moreover, the models were sensitive to an array of variables. The methodological quality of the studies was good. Conclusion This systematic review led to inconclusive and inconsistent results pertinent to the economic profile of TAVI technology. It also highlighted areas which merit further research regarding the pillars of cost-effectiveness analysis such as modeling, the extrapolation of available data and the uncertainty of the evidence. A thorough assessment of the patient should proceed any decision-making.
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Affiliation(s)
- Panagiotis Petrou
- University of Nicosia, School of Sciences and Engineering, Pharmacy School, Pharmacoepidemiology-Pharmacovigilance, Nicosia, Cyprus
- University of Nicosia, Department of Life and Health Sciences, School of Sciences and Engineering, Pharmacoepidemiology-Pharmacovigilance, Nicosia, Cyprus
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24
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O'Byrne ML, Wilensky R, Glatz AC. Incorporating economic analysis in interventional cardiology research. Catheter Cardiovasc Interv 2023; 101:122-130. [PMID: 36480805 DOI: 10.1002/ccd.30506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 11/08/2022] [Accepted: 11/19/2022] [Indexed: 12/13/2022]
Abstract
Evaluative research in interventional cardiology has focused on clinical and technical outcomes. Inclusion of economic data can enhance evaluative research by quantifying the relative economic burden incurred by different therapies. When combined with clinical outcomes, cost data can provide a measure of value (e.g., marginal cost-effectiveness). In some select situations, cost data can also be used as surrogates for complexity of care and morbidity. In this narrative review, we aim to provide a framework for the application of cost data in clinical trials and observational research, detailing how to incorporate this kind of data into interventional cardiology research.
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Affiliation(s)
- Michael L O'Byrne
- Department of Pediatrics, Division of Cardiology and Clinical Futures, The Children's Hospital of Philadelphia, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute For Healthcare Economics, The University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Cardiovascular Outcomes, Quality, and Evaluative Research, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Robert Wilensky
- Center for Cardiovascular Outcomes, Quality, and Evaluative Research, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Internal Medicine, Division of Cardiology, The Hospital of The University of Pennsylvania, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andrew C Glatz
- Department of Pediatrics, Division of Cardiology, Washington University School of Medicine, and St. Louis Children's Hospital, St. Louis, Missouri, USA
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25
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Ashraf M, Carnahan RM. Role of Changing Procedural Characteristics Versus Changing Risk Profile in Age‐Based Trends of Outcomes in Patients With Transfemoral Transcatheter Aortic Valve Replacement From 2012 to 2018: A Nationwide Analysis. J Am Heart Assoc 2022; 11:e026812. [DOI: 10.1161/jaha.122.026812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background
The trends in outcomes in patients who undergo transcatheter aortic valve replacement are well described in the literature. Some of these trends are driven by the decreasing risk profile of patients because of changing indications for transcatheter aortic valve replacement. We aimed to evaluate these trends in different age groups and quantify how much of these trends are driven by changes in procedural characteristics.
Methods and Results
Using the National Inpatient Sample from 2012 to 2018, we identified 204 230 adult patients who underwent transfemoral aortic valve replacement. The study's primary objective was to evaluate the changes in age‐based trends in in‐hospital mortality driven by changes in procedural characteristics over time. The secondary objectives were to evaluate similar trends in cardiac and noncardiac complications and resource use. Univariate and multivariate linear and logistic regression were used to obtain effect sizes. From 2012 to 2018, in‐hospital mortality decreased from 1.8% to 0.79% in the age group 18 to 64 years, from 3.8% to 1.6% in the age group 65 to 80 years, and from 5.3% to 1.5% in the age group >80 years (
P
trend<0.01 for all age groups); these trends remained statistically significant on adjusted analysis except in patients aged 18 to 64 years. The other outcomes also showed variable trends over time. Length of stay, cost, and early discharge rates improved even after adjusting for comorbidities, which is likely attributable to improvement in procedural characteristics.
Conclusions
The changes in outcomes related to transcatheter aortic valve replacement are partly driven by changing patient risk profiles over time, but procedural characteristics have likely contributed to these trends in all age groups.
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Affiliation(s)
- Muddasir Ashraf
- Aurora Cardiovascular and Thoracic Services Aurora Sinai/Aurora St. Luke’s Medical Centers, Advocate Aurora Health Milwaukee WI
| | - Ryan M. Carnahan
- Department of Epidemiology The University of Iowa College of Public Health Iowa City IA
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26
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Butala NM, Wood DA, Li H, Chinnakondepalli K, Lauck SB, Sathananthan J, Cairns JA, Magnuson EA, Barker M, Webb JG, Welsh R, Cheung A, Ye J, Velianou JL, Wijeysundera HC, Asgar A, Kodali S, Thourani VH, Cohen DJ. Economics of Minimalist Transcatheter Aortic Valve Replacement: Results From the 3M-TAVR Economic Study. Circ Cardiovasc Interv 2022; 15:e012168. [PMID: 36256698 PMCID: PMC9575578 DOI: 10.1161/circinterventions.122.012168] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND The 3M-TAVR trial (3M-Transcatheter Aortic Valve Replacement) demonstrated the feasibility and safety of next-day hospital discharge after transfemoral TAVR with implementation of a minimalist pathway. However, the economic impact of this approach is unknown. Therefore, we evaluated costs for patients undergoing minimalist TAVR compared with conventional TAVR. METHODS We used propensity matching to compare resource utilization and costs (from a US health care system perspective) for patients in the 3M-TAVR trial with those for transfemoral TAVR patients enrolled in the contemporaneous S3i trial (PARTNER SAPIEN-3 Intermediate Risk). Procedural costs were estimated using measured resource utilization for both groups. For the S3i group, all other costs through 30-day follow-up were assessed by linkage with Medicare claims; for 3M, these costs were assessed using regression models derived from S3i cost and resource utilization data. RESULTS After 1:1 propensity matching, 351 pairs were included in our study (mean age 82, mean Society of Thoracic Surgery risk score 5.3%). There were no differences in death, stroke, or rehospitalization between the 3M-TAVR and S3i groups through 30-day follow-up. Index hospitalization costs were $10 843/patient lower in the 3M-TAVR cohort, driven by reductions in procedure duration, anesthesia costs, and length of stay. Between discharge and 30 days, costs were similar for the 2 groups such that cumulative 30-day costs were $11 305/patient lower in the 3M-TAVR cohort compared with the S3i cohort ($49 425 versus $60 729, 95% CI for difference $9378 to $13 138; P<0.001). CONCLUSIONS Compared with conventional transfemoral TAVR, use of a minimalist pathway in intermediate-risk patients was associated with similar clinical outcomes and substantial in-hospital cost savings, which were sustained through 30 days. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT02287662.
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Affiliation(s)
- Neel M. Butala
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora (N.M.B.)
| | - David A. Wood
- Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, Canada (D.A.W., S.B.L., J.S., J.A.C., M.B., J.G.W., A.C., J.Y.)
| | - Haiyan Li
- St Luke’s Mid-America Heart Institute, Kansas City, MO (H.L., K.C., E.A.M.)
| | | | - Sandra B. Lauck
- Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, Canada (D.A.W., S.B.L., J.S., J.A.C., M.B., J.G.W., A.C., J.Y.)
| | - Janarthanan Sathananthan
- Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, Canada (D.A.W., S.B.L., J.S., J.A.C., M.B., J.G.W., A.C., J.Y.)
| | - John A. Cairns
- Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, Canada (D.A.W., S.B.L., J.S., J.A.C., M.B., J.G.W., A.C., J.Y.)
| | | | - Madeleine Barker
- Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, Canada (D.A.W., S.B.L., J.S., J.A.C., M.B., J.G.W., A.C., J.Y.)
| | - John G. Webb
- Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, Canada (D.A.W., S.B.L., J.S., J.A.C., M.B., J.G.W., A.C., J.Y.)
| | - Robert Welsh
- Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Canada (R.W.)
| | - Anson Cheung
- Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, Canada (D.A.W., S.B.L., J.S., J.A.C., M.B., J.G.W., A.C., J.Y.)
| | - Jian Ye
- Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, Canada (D.A.W., S.B.L., J.S., J.A.C., M.B., J.G.W., A.C., J.Y.)
| | - James L. Velianou
- Division of Cardiology, Department of Medicine, Hamilton Health Sciences, McMaster University, Ontario, Canada (J.L.V.)
| | | | - Anita Asgar
- Montreal Heart Institute, Quebec, Canada (A.A.)
| | - Susheel Kodali
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, NY (S.K.)
| | | | - David J. Cohen
- Cardiovascular Research Foundation, New York, NY (D.J.C.).,St Francis Hospital and Heart Center, Roslyn, NY (D.J.C.)
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Holmes HR, Falasa M, Neal D, Choi CY, Park K, Bavry AA, Freeman KA, Manning EW, Stinson WW, Jeng EI. Monitored Anesthesia Care Versus General Anesthesia for Transcatheter Aortic Valve Replacement. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2022; 17:401-408. [PMID: 36217748 DOI: 10.1177/15569845221124113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Monitored anesthesia care (MAC) has been increasingly used in lieu of general anesthesia (GA) for transcatheter aortic valve replacement (TAVR). We sought to compare outcomes and in-hospital costs between MAC and GA for TAVR at a Veterans Affairs Medical Center. METHODS A single-center retrospective review was performed of 349 patients who underwent transfemoral TAVR (MAC, n = 244 vs GA, n = 105) from January 2014 to December 2019. Baseline patient characteristics, operating room (OR) time, intensive care unit (ICU) length of stay (LOS), and cost, total LOS, hospital cost, total cost, and complication rates were collected. Propensity matching was performed and resulted in 83 matched pairs. RESULTS In the unmatched TAVR cohort, MAC TAVR was associated with reduced OR time (146 vs 198 min, P < 0.001), ICU LOS (1.4 vs 1.8 days, P < 0.001), total hospital LOS (3.4 vs 5.4 days, P < 0.001), and lower index total cost ($81,300 vs $85,400, P = 0.010). After propensity matching, MAC TAVR patients had reduced OR time (146 vs 196 min, P < 0.05), ICU LOS (1.2 vs 1.7 days, P = 0.006), total LOS (3.5 vs 5.1 days, P = 0.001), and 180-day mortality (2.4% vs 12%, P < 0.03). There was no difference in total hospitalization cost or total cost. CONCLUSIONS In propensity-matched groups, TAVR utilizing MAC is associated with improved OR time efficiency, decreased LOS, and a reduction in 180-day mortality but no significant difference in cost.
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Affiliation(s)
- Henry R Holmes
- Division of Cardiovascular Surgery, Department of Surgery, University of Florida Health, Gainesville, FL, USA
| | - Matheus Falasa
- Division of Cardiovascular Surgery, Department of Surgery, University of Florida Health, Gainesville, FL, USA
| | - Daniel Neal
- Department of Surgery, University of Florida Health, Gainesville, FL, USA
| | - Calvin Y Choi
- Division of Cardiology, Department of Medicine, University of Florida Health, Gainesville, FL, USA.,Division of Cardiology, Department of Medicine, North Florida/South Georgia Veterans Health System, Gainesville, FL, USA
| | - Ki Park
- Division of Cardiology, Department of Medicine, University of Florida Health, Gainesville, FL, USA.,Division of Cardiology, Department of Medicine, North Florida/South Georgia Veterans Health System, Gainesville, FL, USA
| | - Anthony A Bavry
- Division of Cardiology, Department of Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Kirsten A Freeman
- Division of Cardiovascular Surgery, Department of Surgery, University of Florida Health, Gainesville, FL, USA.,Division of Thoracic and Cardiovascular Surgery, Department of Surgery, North Florida/South Georgia Veterans Health System, Gainesville, FL, USA
| | - Eddie W Manning
- Division of Cardiovascular Surgery, Department of Surgery, University of Florida Health, Gainesville, FL, USA.,Division of Thoracic and Cardiovascular Surgery, Department of Surgery, North Florida/South Georgia Veterans Health System, Gainesville, FL, USA
| | - Wade W Stinson
- Division of Cardiovascular Surgery, Department of Surgery, University of Florida Health, Gainesville, FL, USA.,Division of Thoracic and Cardiovascular Surgery, Department of Surgery, North Florida/South Georgia Veterans Health System, Gainesville, FL, USA
| | - Eric I Jeng
- Division of Cardiovascular Surgery, Department of Surgery, University of Florida Health, Gainesville, FL, USA
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Elkaryoni A, Cohen DJ, Lopez JJ, Huded CP, Kennedy KF, Arnold SV. Trends in invasive treatment of patients hospitalized with aortic stenosis complicated by cardiogenic shock. Catheter Cardiovasc Interv 2022; 100:1110-1116. [PMID: 36168864 DOI: 10.1002/ccd.30413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 08/29/2022] [Accepted: 09/07/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Before the development of transcatheter aortic valve replacement (TAVR), balloon aortic valvuloplasty (BAV) was the only potential nonsurgical intervention for patients with aortic stenosis complicated by cardiogenic shock. Emergent TAVR is now an option and has shown acceptable outcomes compared with elective TAVR. We explored how treatment patterns for aortic stenosis and cardiogenic shock among patients received invasive intervention have shifted since TAVR was introduced. METHODS We used the Nationwide In patients Sample to identify nonelective hospitalizations for patient with aortic stenosis complicated by cardiogenic shock who received invasive treatment (TAVR, BAV, or surgical aortic valve replacement [SAVR]). We explored the proportion treated with each treatment modality over time, the patient characteristics and in-hospital mortality associated with each treatment, and used multivariable logistic regression to examine whether changes in in-hospital mortality over time differed by treatment. RESULTS Between 2010 and 2019, we identified 9899 hospitalizations for decompensated aortic stenosis with cardiogenic shock during which patients received invasive treatment (TAVR 17.7%, BAV 20.2%, SAVR 62.1%). Use of both TAVR and BAV has increased over time compared with SAVR (TAVR 6.6% ≥ 33.8%, BAV 8.4% ≥ 23.2%, SAVR 91.6% ≥ 43.0%; p < 0.001 for trend). The overall in-hospital mortality rate was 21.0%, which decreased over time for all treatments (TAVR 20.0% ≥ 18.8%, BAV 66.0% ≥ 25.5%, SAVR 17.7% ≥ 11.8%; linear trend p < 0.001 for each), with lower mortality for TAVR versus BAV at all time points. Patients treated with TAVR (vs. BAV) were less likely to require mechanical ventilation (36.8% vs. 46.3%, p < 0.001) or mechanical circulatory support (22.5% vs. 29.9%, p < 0.001). In the multivariable analysis, the interaction between treatment and time was not significant (p = 0.245), indicating the reduction in in-hospital mortality over time did not differ among the treatments. CONCLUSIONS Since the introduction of TAVR, there has been a shift toward increased use of nonsurgical invasive treatments (both BAV and TAVR) for aortic stenosis and cardiogenic shock. Although in-hospital mortality has declined, it remains high in all groups, but particularly among patients treated with BAV, where the severity of cardiogenic shock appears to be higher than in those treated with other modalities.
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Affiliation(s)
- Ahmed Elkaryoni
- Department of Internal Medicine, Division of Cardiovascular Disease, Loyola Stritch School of Medicine, Loyola University Medical Center, Maywood, Illinois, USA
| | - David J Cohen
- Department of Internal Medicine, Division of Cardiovascular disease, St. Francis Hospital & Heart Center, Roslyn, New York, USA.,Department of Internal Medicine, Division of Cardiovascular disease, Cardiovascular Research Foundation, New York, New York, USA
| | - John J Lopez
- Department of Internal Medicine, Division of Cardiovascular Disease, Loyola Stritch School of Medicine, Loyola University Medical Center, Maywood, Illinois, USA
| | - Chetan P Huded
- Department of Internal Medicine, Division of Cardiovascular disease, Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA.,Department of Internal Medicine, Division of Cardiovascular disease, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Kevin F Kennedy
- Department of Internal Medicine, Division of Cardiovascular disease, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Suzanne V Arnold
- Department of Internal Medicine, Division of Cardiovascular disease, Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA.,Department of Internal Medicine, Division of Cardiovascular disease, University of Missouri-Kansas City, Kansas City, Missouri, USA
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Acute Decompensated Aortic Stenosis: State of the Art Review. Curr Probl Cardiol 2022; 48:101422. [PMID: 36167225 DOI: 10.1016/j.cpcardiol.2022.101422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 09/21/2022] [Indexed: 11/21/2022]
Abstract
Aortic stenosis (AS) is a progressive disease that carries a poor prognosis. Patients are managed conservatively until satisfying an indication for transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement (SAVR) based on AS severity and the presence of symptoms or adverse impact on the myocardium. Up to 1 in 3 TAVIs are performed for patients with acute symptoms of dyspnoea at rest, angina, and/or syncope - termed acute decompensated aortic stenosis (ADAS) and require urgent aortic valve replacement. These patients have longer hospital length of stay, undergo physical deconditioning, have a higher rate of acute kidney injury and mortality compared to stable patients with less severe symptoms. There is an urgent need to prevent ADAS and to deliver pathways to manage and improve ADAS-related outcomes. We provide here a contemporary review on epidemiological and pathophysiological aspects of ADAS, with a focus on the impact of ADAS from clinical and economic perspectives. We will offer also a global overview of the available evidence for treatment of ADAS and with priorities suggested for addressing current gaps in the literature and unmet clinical needs to improve outcomes for AS patients.
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Tan ECH, Lee YT, Kuo YC, Tsao TP, Lee KC, Hsiung MC, Wei J, Lin KC, Yin WH. Clinical outcomes and cumulative healthcare costs of TAVR vs. SAVR in Asia. Front Cardiovasc Med 2022; 9:973889. [PMID: 36211540 PMCID: PMC9532629 DOI: 10.3389/fcvm.2022.973889] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 08/30/2022] [Indexed: 11/23/2022] Open
Abstract
Objectives This study compared transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) in terms of short- and long-term effectiveness. Methods This retrospective cohort study based on nationwide National Health Insurance claims data and Cause of Death data focused on adult patients (n = 3,643) who received SAVR (79%) or TAVR (21%) between 2015 and 2019. Propensity score overlap weighting was applied to account for selection bias. Primary outcomes included all-cause mortality (ACM), hospitalization for heart failure, and a composite endpoint of major adverse cardiac events (MACE). Secondary outcomes included medical utilization, hospital stay, and total medical costs at index admission for the procedure and in various post-procedure periods. The Cox proportional-hazard model with competing risk was used to investigate survival and incidental health outcomes. Generalized estimation equation (GEE) models were used to estimate differences in the utilization of medical resources and overall costs. Results After weighting, the mean age of the patients was 77.98 ± 5.86 years in the TAVR group and 77.98 ± 2.55 years in the SAVR group. More than half of the patients were female (53.94%). The incidence of negative outcomes was lower in the TAVR group than in the SAVR group, including 1-year ACM (11.39 vs. 17.98%) and 3-year ACM (15.77 vs. 23.85%). The risk of ACM was lower in the TAVR group (HR [95% CI]: 0.61 [0.44–0.84]; P = 0.002) as was the risk of CV death (HR [95% CI]: 0.47 [0.30–0.74]; P = 0.001) or MACE (HR [95% CI]: 0.66 [0.46–0.96]; P = 0.0274). Total medical costs were significantly higher in the TAVR group than in the SAVR in the first year after the procedure ($1,271.89 ± 4,048.36 vs. $887.20 ± 978.51; P = 0.0266); however, costs were similar in the second and third years after the procedure. The cumulative total medical costs after the procedure were significantly higher in the TAVR group than in the SAVR group (adjusted difference: $420.49 ± 176.48; P = 0.0172). Conclusion In this real-world cohort of patients with aortic stenosis, TAVR proved superior to SAVR in terms of clinical outcomes and survival with comparable medical utilization after the procedure.
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Affiliation(s)
- Elise Chia-Hui Tan
- Department of Health Service Administration, China Medical University, Taichung, Taiwan
- Department of Pharmacy, Institute of Hospital and Health Care Administration, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yung-Tsai Lee
- Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Yu Chen Kuo
- Department of Health Service Administration, China Medical University, Taichung, Taiwan
| | - Tien-Ping Tsao
- Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan
- Faculty of Medicine, National Defense Medical Center, Taipei, Taiwan
| | - Kuo-Chen Lee
- Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan
| | | | - Jeng Wei
- Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Kuan-Chia Lin
- Community Research Center, Institute of Hospital and Health Care Administration, National Yang Ming Chiao Tung University, Taipei, Taiwan
- *Correspondence: Kuan-Chia Lin
| | - Wei-Hsian Yin
- Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan
- Faculty of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Wei-Hsian Yin
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Reza J, Mila A, Ledzian B, Sun J, Silvestry S. Incremental cost-effectiveness of extracorporeal membranous oxygenation as a bridge to cardiac transplant or left ventricular assist device placement in patients with refractory cardiogenic shock. JTCVS OPEN 2022; 11:132-145. [PMID: 36172402 PMCID: PMC9510879 DOI: 10.1016/j.xjon.2022.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 03/26/2022] [Accepted: 06/27/2022] [Indexed: 11/18/2022]
Abstract
Objective Emerging literature has described using venoarterial extracorporeal membranous oxygenation (ECMO) as a bridge to transplant or left ventricular assist device (LVAD) placement. We sought to identify the incremental cost-effectiveness ratio (ICER) of ECMO used as a bridge to cardiac transplant or LVAD. Methods Patients with refractory cardiogenic shock who received venoarterial ECMO and were bridged to either cardiac transplant (n = 7) or a HeartMate 3 LVAD (n = 6) placement were included. Markov modeling was used, comparing ECMO bridging with non–ECMO-bridged patients. Cohorts entered the model alive and at every 1-year cycle, were exposed to risk of death, and ran forward for 20 years after transplant or LVAD. Results Patients bridged with ECMO to cardiac transplant were stratified as group 1 whereas those bridged with ECMO to LVAD were stratified as group 2. The average ECMO run was 3 days in group 1 versus 11 days in group 2. Among group 1 patients, the ICER was $246,629 but was paired with a longer life expectancy. The ICER of group 2 patients was –$107,088 and was not paired with a longer life expectancy. The average inpatient cost for group 1 was found to be $636,023 versus $769,471 for group 2 patients. The average inpatient costs for patients not bridged to ECMO who received cardiac transplant or LVAD was $538,928 and $325,242, respectively. Conclusions Using ECMO to bridge to transplant or LVAD placement is not cost effective. However, patients bridged to transplant are paired with longer life expectancy in contrast to patients bridged to LVAD.
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Affiliation(s)
- Joseph Reza
- General Surgery Residency Program, AdventHealth Orlando, Orlando, Fla
- Address for reprints: Joseph Reza, MD, 3401 N. Broad St. C501. Philadelphia, PA 19140.
| | - Ashley Mila
- General Surgery Residency Program, AdventHealth Orlando, Orlando, Fla
| | - Bradford Ledzian
- AdventHealth Transplant Institute, Thoracic Transplant and Cardiovascular Surgery, AdventHealth Orlando, Orlando, Fla
| | - Jingwei Sun
- Center for Academic Research, AdventHealth Orlando, Orlando, Fla
| | - Scott Silvestry
- AdventHealth Transplant Institute, Thoracic Transplant and Cardiovascular Surgery, AdventHealth Orlando, Orlando, Fla
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See-Toh RSE, Wong XY, Mahboobani KSKH, Soon SS, Kearns B, Cooper K, Ho KW, Kuntjoro I, Ng K. Cost-effectiveness of transcatheter aortic valve implantation in patients with severe symptomatic aortic stenosis of intermediate surgical risk in Singapore. BMC Health Serv Res 2022; 22:994. [PMID: 35927703 PMCID: PMC9354430 DOI: 10.1186/s12913-022-08369-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 07/18/2022] [Indexed: 11/16/2022] Open
Abstract
Objective The objective was to assess the cost-effectiveness of transcatheter aortic valve implantation (TAVI) in patients with severe aortic stenosis with intermediate surgical risk in Singapore. Methods A de novo Markov model with three health states – stroke with long-term sequelae, no stroke, and death – was developed and simulated using Monte Carlo simulations with 10,000 iterations over a five-year time horizon from the Singapore healthcare system perspective. A 3% annual discount rate for costs and outcomes and monthly cycle lengths were used. By applying the longest available published clinical evidence, simulated patients received either TAVI or surgical aortic valve replacement (SAVR) and were at risk of adverse events (AEs) such as moderate-to-severe paravalvular aortic regurgitation (PAR). Results When five-year PARTNER 2A data was applied, base-case analyses showed that the incremental cost-effectiveness ratio (ICER) for TAVI compared to SAVR was US$315,760 per quality-adjusted life year (QALY) gained. The high ICER was due to high incremental implantation and procedure costs of TAVI compared to SAVR, and marginal improvement of 0.10 QALYs as simulated mortality of TAVI exceeded SAVR at 3.75 years post-implantation. One-way sensitivity analysis showed that the ICERs were most sensitive to cost of PAR, utility values of SAVR patients, and cost of TAVI and SAVR implants and procedures. When disutilities for AEs were additionally applied, the ICER decreased to US$300,070 per QALY gained. TAVI was dominated by SAVR when the time horizon increased to 20 years. Clinical outcomes projected from one-year PARTNER S3i data further reduced the ICER to US$86,337 per QALY gained for TAVI, assuming early all-cause mortality benefits from TAVI continued to persist. This assumption was undermined when longer term data showed that TAVI’s early mortality benefits diminished at five years. Limitations and conclusion TAVI is unlikely to be cost-effective in intermediate surgical-risk patients compared to SAVR in Singapore. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08369-5.
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Affiliation(s)
| | - Xin Yi Wong
- Agency for Care Effectiveness, Ministry of Health, Singapore, Singapore
| | | | - Swee Sung Soon
- Agency for Care Effectiveness, Ministry of Health, Singapore, Singapore
| | - Benjamin Kearns
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Katy Cooper
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | | | | | - Kwong Ng
- Agency for Care Effectiveness, Ministry of Health, Singapore, Singapore.
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Khan S, Shi W, Kaneko T, Baron SJ. The Evolving Role of the Multidisciplinary Heart Team in Aortic Stenosis. US CARDIOLOGY REVIEW 2022. [DOI: 10.15420/usc.2022.04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Transcatheter aortic valve replacement has transformed the paradigm of care for patients with severe aortic stenosis (AS). With transcatheter aortic valve replacement now commercially approved for AS patients of all surgical risk, clinical decision-making regarding the initial mode of valve replacement (e.g. surgical versus transcatheter) and prosthesis type has become even more complex. The updated American College of Cardiology/American Heart Association and European Society of Cardiology/European Association for Cardio-Thoracic Surgery guidelines on valvular heart disease offer a strong foundation from which to address the nuances of the treatment of AS; however, there remain several clinical scenarios for which evidence and thus definitive societal recommendations are lacking. As such, the heart team continues to play an invaluable role in the management of the AS patient by combining available scientific evidence, expertise across disciplines, and the patient’s preferences to optimize individualized patient care and healthcare resource usage.
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Affiliation(s)
- Sahoor Khan
- Department of Cardiology, Lahey Hospital and Medical Center, Burlington, MA
| | - William Shi
- Department of Cardiac Surgery, Brigham and Women’s Hospital, Boston, MA
| | - Tsuyoshi Kaneko
- Department of Cardiac Surgery, Brigham and Women’s Hospital, Boston, MA
| | - Suzanne J Baron
- Department of Cardiology, Lahey Hospital and Medical Center, Burlington, MA; Baim Institute for Clinical Research, Boston, MA
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Update on Minimalist TAVR Care Pathways: Approaches to Care in 2022. Curr Cardiol Rep 2022; 24:1179-1187. [PMID: 35767177 PMCID: PMC9244066 DOI: 10.1007/s11886-022-01737-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/03/2022] [Indexed: 11/20/2022]
Abstract
Purpose of Review This review summarizes current data supporting a minimalist TAVR approach and identifies the need for additional study to optimize TAVR care. The authors discuss future directions of the TAVR landscape and how this necessitates evolution of minimalist care pathways. Recent Findings Transcatheter aortic valve replacement (TAVR) has become a mainstay in the treatment of aortic stenosis since the initial procedure in 2002. Recently, attention has shifted to TAVR optimization and the minimalist approach with a focus on minimizing procedural sedation, protocolization of perioperative management, and prioritization on early discharge. This approach has been shown to be safe and reduce procedure time, length of stay, and overall cost for hospital systems. Summary The minimalist care pathway avoids general anesthesia, shortens procedure time and length of stay, and reduces cost without changing mortality or readmission rates at 30 days. A variety of protocols have been proposed without a clear consensus on specific components or patient eligibility. There is a continued need for data regarding patient risk stratification, valve selection, and discharge strategy as TAVR becomes increasingly common.
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Elzanaty AM, Maraey A, Elbadawi A, Khalil M, Hashim A, Vyas R, Moustafa A, Ramanthan PK, Mentias A, Abbott JD, Aronow HD, Kapadia S, Saad M. Early versus late discharge after transcatheter aortic valve replacement and readmissions for permanent pacemaker implantation. Catheter Cardiovasc Interv 2022; 100:245-253. [PMID: 35758231 DOI: 10.1002/ccd.30299] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 05/03/2022] [Accepted: 06/01/2022] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To examine the rate of readmission for permanent pacemaker (PPM) implantation with early versus late discharge after transcatheter aortic valve replacement (TAVR). BACKGROUND There is a current trend toward early discharge after TAVR. However, paucity of data exists on the impact of such practice on readmissions for PPM implantation. METHODS The Nationwide Readmission Database 2016-2018 was queried for all hospitalizations where patients underwent TAVR. Hospitalizations were stratified into early (Days 0 and 1) versus late (≥Day 2) discharge groups. Observations in which PPM was required in the index admission were excluded. Multivariable regression analyses involving patient- and hospital-related variables were utilized. The primary outcome was 90-day readmission for PPM implantation. RESULTS The final analysis included 68,482 TAVR hospitalizations, 20,261 (29.6%) with early versus 48,221 (70.4%) with late discharge. Early discharge after TAVR increased over the study period (16.2% in 2016 vs. 37.9% in 2018, Ptrend < 0.01). Nevertheless, 90-day readmission for PPM implantation remained stable (1.8% in 2016 vs. 2.0% in 2018, Ptrend = 0.32). The 90-day readmission rate for PPM implantation (2.0% vs. 1.8%; adjusted odds ratio: 1.15; 95% confidence interval: 0.95-1.39; p = 0.15) and median time-to-readmission (5 days [interquartile range, IQR 3-9] vs. 5 days [IQR 3-14], p = 0.92) were similar with early versus late discharge. Similar rates were observed regardless of whether readmission was elective versus not. Early discharge was associated with lower hospitalization cost ($39,990 ± $13,681 vs. $46,750 ± $18,218, p < 0.01) compared with late discharge. CONCLUSION In patients who did not require PPM during the index TAVR hospitalization, the rate of readmission for PPM implantation was similar with early versus late discharge.
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Affiliation(s)
- Ahmed M Elzanaty
- Division of Cardiovascular Medicine, University of Toledo, Toledo, Ohio, USA
| | - Ahmed Maraey
- Department of Internal Medicine, University of North Dakota, Bismarck, North Dakota, USA
| | - Ayman Elbadawi
- Section of Cardiology, Baylor College of Medicine, Houston, Texas, USA
| | - Mahmoud Khalil
- Department of Internal Medicine, Lincoln Medical Center, New York, New York, USA
| | - Ahmed Hashim
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Rohit Vyas
- Division of Cardiovascular Medicine, University of Toledo, Toledo, Ohio, USA
| | | | | | - Amgad Mentias
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - J Dawn Abbott
- Department of Medicine, Division of Cardiology, Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Lifespan Cardiovascular Institute, Providence, Rhode Island, USA
| | - Herbert D Aronow
- Department of Medicine, Division of Cardiology, Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Lifespan Cardiovascular Institute, Providence, Rhode Island, USA
| | - Samir Kapadia
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Marwan Saad
- Department of Medicine, Division of Cardiology, Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Lifespan Cardiovascular Institute, Providence, Rhode Island, USA
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Zhang W, Lou Y, Liu Y, Wang H, Zhang C, Qian L. Economic Evaluation of Transcatheter Aortic Valve Replacement Compared to Surgical Aortic Valve Replacement in Chinese Intermediate-Risk Patients. Front Cardiovasc Med 2022; 9:896062. [PMID: 35722099 PMCID: PMC9204519 DOI: 10.3389/fcvm.2022.896062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 04/29/2022] [Indexed: 11/25/2022] Open
Abstract
Background Aortic stenosis (AS) is a severe disease that causes heart failure and sudden death. Transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) are both recommended for patients with intermediate surgical risk, but the cost-effectiveness of TAVR compared to SAVR in China has not been investigated. Methods A combined decision tree and Markov model were conducted to compare the cost-effectiveness of TAVR versus SAVR with a 5-year simulation. The primary outcome was the incremental cost-effectiveness ratio (ICER), a ratio of incremental costs to incremental quality-adjusted life-year (QALY). One-way sensitive analysis and probabilistic sensitivity analysis (PSA) were conducted to test the robustness of the model. Results After a simulation of 5 years, the costs of TAVR and SAVR were 54,573 and 35,002 USD, respectively, and the corresponding effectiveness was 2.826 versus 2.712 QALY, respectively. The ICER for the TAVR versus SAVR comparison was 170,056 USD/QALY, which was three times higher than the per capita gross domestic product (GDP) in China. One-way sensitive analysis showed that the cost of the TAVR device impacted the ICER. The TAVR could be cost-effective only in the case where its cost is lowered to 29,766 USD. Conclusion TAVR is currently not cost-effective in China, but it could be cost-effective with a reduction of costs to 29,766 USD, which is approximately 65% of the current price.
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Affiliation(s)
- Weicong Zhang
- Department of Ultrasound, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Yake Lou
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yujiang Liu
- Department of Ultrasound, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Hongwei Wang
- Department of Radiology, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China
| | - Chun Zhang
- Department of Ultrasound, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- *Correspondence: Chun Zhang,
| | - Linxue Qian
- Department of Ultrasound, Beijing Friendship Hospital, Capital Medical University, Beijing, China
- Linxue Qian,
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Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Rafael Sádaba J, Tribouilloy C, Wojakowski W. Guía ESC/EACTS 2021 sobre el diagnóstico y tratamiento de las valvulopatías. Rev Esp Cardiol 2022. [DOI: 10.1016/j.recesp.2021.11.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Pinar E, García de Lara J, Hurtado J, Robles M, Leithold G, Martí-Sánchez B, Cuervo J, Pascual DA, Estévez-Carrillo A, Crespo C. Análisis coste-efectividad del implante percutáneo de válvula aórtica SAPIEN 3 en pacientes con estenosis aórtica grave sintomática. Rev Esp Cardiol 2022. [DOI: 10.1016/j.recesp.2021.02.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Gilard M, Eltchaninoff H, Iung B, Lefèvre T, Spaulding C, Dumonteil N, Mutuon P, Roussel C, Candolfi P, de Pouvourville G, Green M, Shore J. Cost-Effectiveness Analysis of SAPIEN 3 Transcatheter Aortic Valve Implantation Procedure Compared With Surgery in Patients With Severe Aortic Stenosis at Low Risk of Surgical Mortality in France. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2022; 25:605-613. [PMID: 35365304 DOI: 10.1016/j.jval.2021.10.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 09/03/2021] [Accepted: 10/05/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVES The clinical and cost-saving benefits of transcatheter aortic valve implantation (TAVI) over surgical aortic valve replacement (SAVR) in patients with severe aortic stenosis who are at high or intermediate risk of surgical mortality are supported by a growing evidence base. The PARTNER 3 trial (Placement of AoRTic TraNscathetER Valve Trial) demonstrated clinical benefits with SAPIEN 3 TAVI compared with SAVR in selected patients at low risk of surgical mortality. This study uses PARTNER 3 outcomes in combination with a French national hospital claim database to inform a cost-utility model and examine the cost implications of TAVI over SAVR in a low-risk population. METHODS A 2-stage cost-utility analysis was developed to estimate changes in both direct healthcare costs and health-related quality of life using TAVI with SAPIEN 3 compared with SAVR. Early adverse events associated with TAVI were captured using the PARTNER 3 data set. These data fed into a Markov model that captured longer-term outcomes of patients, after TAVI or SAVR intervention. RESULTS TAVI with SAPIEN 3 offers meaningful benefits over SAVR in providing both cost saving (€12 742 per patient) and generating greater quality-adjusted life-years (0.89 per patient). These results are robust with TAVI with SAPIEN 3 remaining dominant across several scenarios and deterministic and probabilistic sensitivity analyses. CONCLUSIONS This model demonstrated that TAVI with SAPIEN 3 was dominant compared with SAVR in the treatment of patients with severe symptomatic aortic stenosis who are at low risk of surgical mortality. These findings should help policy makers in developing informed approaches to intervention selection for this patient population.
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Affiliation(s)
- Martine Gilard
- Centre Hospitalier Régional et Universitaire de Brest, Brest, France.
| | - Hélène Eltchaninoff
- Department of Cardiology, CHU Rouen, UNIROUEN, Normandie Univ, Rouen, France
| | - Bernard Iung
- Hôpital Bichat Claude-Bernard (APHP), Paris, France
| | - Thierry Lefèvre
- Hôpital Privé Jacques Cartier, Ramsay-générale de santé, Massy, France
| | | | | | | | | | | | | | - Michelle Green
- York Health Economics Consortium, University of York, York, England, UK
| | - Judith Shore
- York Health Economics Consortium, University of York, York, England, UK
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Cerebral Tissue Oxygen Saturation Is Enhanced in Patients following Transcatheter Aortic Valve Implantation: A Retrospective Study. J Clin Med 2022; 11:jcm11071930. [PMID: 35407537 PMCID: PMC8999949 DOI: 10.3390/jcm11071930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 03/24/2022] [Accepted: 03/28/2022] [Indexed: 11/16/2022] Open
Abstract
Transcatheter aortic valve implantation (TAVI) has emerged as an alternative to surgical aortic valve replacement. The aim of this study was to evaluate whether a relevant alteration in cerebral tissue oxygen saturation (rSO2) could be detected following TAVI. Retrospective data analysis included 275 patients undergoing TAVI between October 2016 and December 2020. Overall, rSO2 significantly increased following TAVI (64.6 ± 10% vs. 68.1 ± 10%, p < 0.01). However, a significant rise was only observed in patients with a preoperative rSO2 < 60%. Of the hemodynamic confounders studied, hemoglobin, mean arterial pressure and blood pH were lowered, while central venous pressure and arterial partial pressure of carbon dioxide (PaCO2) were slightly elevated (PaCO2: 39 (36−43) mmHg vs. 42 (37−47) mmHg, p = 0.03; pH: 7.41 (7.3−7.4) vs. 7.36 (7.3−7.4), p < 0.01). Multivariate linear regression modeling identified only hemoglobin as a predictor of altered rSO2. Patients with a EuroScore II above 4% and an extended ICU stay were found to have lower rSO2, while no difference was observed in patients with postoperative delirium or between the implanted valve types. Further prospective studies that eliminate differences in potential confounding variables are necessary to confirm the rise in rSO2. Future research should provide more information on the value of cerebral oximetry for identifying high-risk patients who will require further clinical interventions in the setting of the TAVI procedure.
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The transcatheter aortic valve implantation: an assessment of the generalizability of the economic evidences following a systematic review. Int J Technol Assess Health Care 2022; 38:e27. [PMID: 35321767 DOI: 10.1017/s0266462321001720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Scientific literature debates on the economic affordability of transcatheter aortic valve implantation (TAVI) in order to give a useful support to decision makers aiming at establishing a reimbursement scheme for TAVI. For this reason, it is important to assess the quality and the generalizability of the existing economic evidences. METHODS The first step was to run a literature search according to a predefined population, intervention, comparator, and outcome on the cost and effectiveness of the TAVI procedure in comparison to medical therapy and traditional surgery. Second, a manual search was carried out on the Web sites of the main HTA agencies. Third, the checklist developed by Augustovski et al. was applied in order to assess the quality and the generalizability of the articles resulting from the selection process. RESULTS Overall, 106 articles were obtained. Of these, sixty-five articles were excluded since the title was not consistent with the objective. Further selection took place after abstract and full-text reading. In the end, thirty-one documents were included for the review. According to the checklist, none of the articles was considered generalizable and only one was considered transferable which compares the TAVI procedure with Medical Management in inoperable patients. CONCLUSIONS Despite the overall quality of the selected studies was considered good, there is still a lack of evidence on whether evidences generated in different contexts can be considered generalizable. Further research on resource consumption and preferences is needed in order to provide decision makers with more robust evidences.
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Baron SJ, Ryan MP, Moore KA, Clancy SJ, Gunnarsson CL. Contemporary Costs Associated With Transcatheter Versus Surgical Aortic Valve Replacement in Medicare Beneficiaries. Circ Cardiovasc Interv 2022; 15:e011295. [PMID: 35193382 DOI: 10.1161/circinterventions.121.011295] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND In patients with severe aortic stenosis, treatment with transcatheter aortic valve replacement (TAVR) has been shown to be cost-effective in the high-risk surgical population and cost-saving in the intermediate-risk population when compared with surgical aortic valve replacement (SAVR) in early pivotal clinical trials. Whether TAVR is associated with comparable or lower costs when compared with SAVR in contemporary clinical practice is unknown. METHODS Using data from the Medicare Dataset Standard Analytic Files 5% Fee for Service database, patients receiving either TAVR or SAVR between 2016 and 2018 were identified. Patients were categorized as low, intermediate, or high mortality risk based on 2 validated indices-the Hospital Frailty Risk Score and the logEuroScore. Health care costs out to 1 year were compared between TAVR and SAVR among the low, intermediate, and high-risk groups, after adjustment for patient demographics. RESULTS Nine thousand seven hundred forty-six patients were identified (4834 TAVR; 3760 SAVR) and included in the analysis. Patients receiving TAVR were older and more likely to be female. Index hospitalization costs were significantly lower with TAVR compared with SAVR across all risk strata (logEuroScore: low: $61 845 versus $68 986; intermediate: $64 658 versus $76 965; high: $65 594 versus $91 005; P<0.001 for all). Follow-up costs through 1 year were generally lower with TAVR and this difference was more pronounced in the low risk groups (logEuroScore: $9763 versus $14 073; Hospital Frailty Risk Score: $10 116 versus $12 880). Accordingly, cumulative 1-year costs were substantially lower with TAVR compared with SAVR. CONCLUSIONS At 1 year, TAVR is associated with lower health care costs across all risk strata when compared with SAVR in contemporary practice. If long-term data continue to demonstrate similar clinical outcomes and valve durability with TAVR and SAVR, these findings suggest that TAVR may be the preferred treatment strategy for patients with aortic stenosis from an economic standpoint.
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Affiliation(s)
- Suzanne J Baron
- Lahey Hospital and Medical Center, Burlington, MA (S.J.B.).,Baim Institute for Clinical Research, Boston, MA (S.J.B.)
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Steitieh D, Sharma N, Singh HS. How Technology Is Changing Interventional Cardiology. CURRENT CARDIOVASCULAR RISK REPORTS 2022. [DOI: 10.1007/s12170-021-00686-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W. 2021 ESC/EACTS Guidelines for the management of valvular heart disease. EUROINTERVENTION 2022; 17:e1126-e1196. [PMID: 34931612 PMCID: PMC9725093 DOI: 10.4244/eij-e-21-00009] [Citation(s) in RCA: 146] [Impact Index Per Article: 73.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Reddy KP, Groeneveld PW, Giri J, Fanaroff AC, Nathan AS. Economic Considerations in Access to Transcatheter Aortic Valve Replacement. Circ Cardiovasc Interv 2022; 15:e011489. [PMID: 35021854 DOI: 10.1161/circinterventions.121.011489] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Transcatheter aortic valve replacement (TAVR) has revolutionized the treatment of aortic stenosis, with the number of procedures and sites offering the procedure steadily rising over the past decade in the United States. Despite this, growth into certain markets has been limited as hospitals have to balance high TAVR costs with the ability to offer a complete array of state-of-the-art therapies for aortic stenosis. This trade-off often results in decreased access to TAVR services by patients cared for in hospitals that cannot afford these services or have difficulty meeting procedural requirements, recruiting skilled physicians, and initiating and then maintaining a functioning TAVR program. The lack of access is more common among patients of color or those who are socioeconomically disadvantaged. The purpose of this review is to describe the hospital-level economic considerations of TAVR in the United States and the resulting effects on geographic, racial, ethnic, and socioeconomic access for Americans.
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Affiliation(s)
- Kriyana P Reddy
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center (K.P.R., P.W.G., J.G., A.C.F., A.S.N.), University of Pennsylvania, Philadelphia
| | - Peter W Groeneveld
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center (K.P.R., P.W.G., J.G., A.C.F., A.S.N.), University of Pennsylvania, Philadelphia.,Leonard Davis Institute of Health Economics (P.W.G., J.G., A.C.F., A.S.N.), University of Pennsylvania, Philadelphia.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA (P.W.G., J.G., A.S.N.)
| | - Jay Giri
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center (K.P.R., P.W.G., J.G., A.C.F., A.S.N.), University of Pennsylvania, Philadelphia.,Leonard Davis Institute of Health Economics (P.W.G., J.G., A.C.F., A.S.N.), University of Pennsylvania, Philadelphia.,Cardiovascular Division (J.G., A.C.F., A.S.N.), Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Alexander C Fanaroff
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center (K.P.R., P.W.G., J.G., A.C.F., A.S.N.), University of Pennsylvania, Philadelphia.,Leonard Davis Institute of Health Economics (P.W.G., J.G., A.C.F., A.S.N.), University of Pennsylvania, Philadelphia.,Cardiovascular Division (J.G., A.C.F., A.S.N.), Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Ashwin S Nathan
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center (K.P.R., P.W.G., J.G., A.C.F., A.S.N.), University of Pennsylvania, Philadelphia.,Leonard Davis Institute of Health Economics (P.W.G., J.G., A.C.F., A.S.N.), University of Pennsylvania, Philadelphia.,Cardiovascular Division (J.G., A.C.F., A.S.N.), Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA (P.W.G., J.G., A.S.N.)
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Carapinha JL, Al-Omar HA, Alqoofi F, Samargandy SA, Candolfi P. Budget impact analysis of transcatheter aortic valve replacement in low, intermediate, and high-risk patients with severe aortic stenosis in Saudi Arabia. J Med Econ 2022; 25:77-86. [PMID: 34927509 DOI: 10.1080/13696998.2021.2020569] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
AIMS A budget impact analysis (BIA) comparing transcatheter aortic valve replacement (TAVR) with SAPIEN 3 and surgical aortic valve replacement (SAVR) for severe, symptomatic aortic stenosis among patients of low, intermediate, and high surgical risk from the perspective of the public and private sectors in Saudi Arabia. MATERIALS AND METHODS A Markov model was developed with six states to calculate the budget impact from time of either TAVR or SAVR intervention up to 5 years. We compared the budget effects of new permanent pacemaker implantation (PPI), new onset atrial fibrillation (AF), major/disabling stroke (MDS), and surgical site infections (SSI). One-way sensitivity analyses (OWSA) were performed on cost and probability inputs. RESULTS Analysis of the base case parameters suggests TAVR vs. SAVR is budget saving among intermediate- and high-risk patients at 5 years. TAVR vs. SAVR for low surgical risk reaches budget neutrality at 5 years. TAVR is associated with higher costs for PPI and budget savings for MDS, AF, and SSI. TAVR also results in savings for non-device costs due to fewer human resource uses and shorter procedure durations. Similarly, TAVR is associated with cost savings due to shorter hospital intensive care unit (ICU) and non-ICU stays. The OWSA consistently revealed that SAVR non-device theater costs were the leading cost driver across all surgical risk levels. LIMITATIONS This is the first budget impact analysis of its kind in Saudi Arabia and future research is needed on costing TAVR and SAVR procedures, the economic impact of SSI, and corroborating estimates for the public and private sectors. CONCLUSIONS Payers, providers, and policymakers increasingly turn to results of BIA to inform technologies affordability decisions. TAVR with SAPIEN 3 appears to generate savings vs. SAVR from a budget impact perspective across various surgical risk levels in Saudi Arabia.
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Affiliation(s)
- João L Carapinha
- Affiliate Assistant Professor of Pharmacy, Northeastern University School of Pharmacy, Boston, MA, USA
- Director, Syenza, Anaheim, CA, USA
| | - Hussain A Al-Omar
- Pharmacoeconomics and Pharmaceutical Policy, Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
- Director for Health Technology Assessment Unit, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Faisal Alqoofi
- Interventional Cardiologist, John Hopkins Aramco Healthcare, Dhahran, Saudi Arabia
| | - Sondos A Samargandy
- Interventional Cardiologist, Interventional Cardiology Division, Adult Cardiology Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Pascal Candolfi
- THV Market Access, Edwards Lifesciences Crop., Nyon, Switzerland
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Sevilla JP, Klusty JM, Song Y, Russo MJ, Thompson CA, Jiao X, Clancy SJ, Bloom DE. Cost-utility and cost-benefit analysis of TAVR availability in the US severe symptomatic aortic stenosis patient population. J Med Econ 2022; 25:1051-1060. [PMID: 35983718 DOI: 10.1080/13696998.2022.2112442] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
AIMS We evaluated the availability of transcatheter aortic valve replacement (TAVR) to determine its value across all severe symptomatic aortic stenosis (SSAS) patients, especially those untreated because of concerns regarding invasive surgical AVR (SAVR) and its impact on active aging. METHODS We performed payer perspective cost-utility analysis (CUA) and societal perspective cost-benefit analysis (CBA). The CBA's benefit measure is active time: salaried labor, unpaid work, and active leisure. The study population is a cohort of US elderly SSAS patients. We compared a "TAVR available" scenario in which SSAS patients distribute themselves across TAVR, SAVR, and medical management (MM); and a "TAVR not available" scenario with only SAVR and MM. We structured each scenario with a decision-tree model of SSAS patient treatment allocation. We measured the association between health and active time in the US Health and Retirement Study and used this association to impute active time to SSAS patients given their health. RESULTS The incremental cost-effectiveness ratio (ICER) and rate of return (RoR) of TAVR availability were $8,533 and 395%, respectively. CUA net monetary benefits (NMB) were $212,199 per patient and $43.4 billion population-wide. CBA NMB were $50,530 per patient and $10.3 billion population-wide. LIMITATIONS Among study limitations were scarcity of evidence regarding key parameters and the lack of long-term survival, health utility, and treatment cost data. Our analysis did not account for TAVR durability, retreatments, and valve-in-valve treatments. CONCLUSION Across risk-, age-, and treatment-eligibility groups, TAVR is the economically optimal treatment choice. It represents strong value-for-money per patient and population-wide. The vast majority of TAVR value involves raising treatment uptake among the untreated.
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Affiliation(s)
- J P Sevilla
- Life Sciences Group, Data for Decisions, LLC, Waltham, MA, USA
| | | | - Younghwan Song
- Department of Economics, Union College, Schenectady, NY, USA
| | - Mark J Russo
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | | | | | | | - David E Bloom
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA, USA
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OUP accepted manuscript. Eur Heart J 2022; 43:2801-2811. [DOI: 10.1093/eurheartj/ehac234] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 04/16/2022] [Accepted: 04/24/2022] [Indexed: 11/12/2022] Open
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Lee CH, Inohara T, Hayashida K, Park DW. Transcatheter Aortic Valve Replacement in Asia: Present Status and Future Perspectives. JACC. ASIA 2021; 1:279-293. [PMID: 36341218 PMCID: PMC9627874 DOI: 10.1016/j.jacasi.2021.10.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 09/01/2021] [Accepted: 10/07/2021] [Indexed: 05/28/2023]
Abstract
Over the last decade, based on evidence from multiple randomized clinical trials, transcatheter aortic valve replacement (TAVR) has become the established treatment for patients with symptomatic severe aortic stenosis. Despite the overwhelming expansion of TAVR in Western countries, the initial uptake and widespread adoption of this procedure have been relatively delayed in Asian countries, owing to the high cost of devices; limited local health and reimbursement policies; and lack of specific training/proctoring program, specialized heart team, or dedicated infrastructure. Furthermore, it has not yet been determined whether there are substantial interracial and ethnic differences in the clinical characteristics, comorbidities, and anatomic features, as well as procedural and long-term outcomes, in patients receiving TAVR. In this review, we provide not only a comprehensive look at the current status and outcomes of TAVR in Asian populations compared with those of Western populations but also a perspective on the future of TAVR in Asia.
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Key Words
- AR, aortic regurgitation
- AS, aortic stenosis
- BAV, bicuspid aortic valve
- BSA, body surface area
- PPI, permanent pacemaker insertion
- PPM, patient-prosthesis mismatch
- PVL, paravalvular leak
- RCT, randomized clinical trial
- SAVR, surgical aortic valve replacement
- STS, Society of Thoracic Surgeons
- TAVR, transcatheter aortic valve replacement
- VHD, valvular heart disease
- aortic stenosis
- outcomes
- race and ethnicity
- valvular disease
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Affiliation(s)
- Cheol Hyun Lee
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Deagu, South Korea
| | - Taku Inohara
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Kentaro Hayashida
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Duk-Woo Park
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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Lorenzoni V, Barbieri G, Saia F, Meucci F, Martinelli GL, Cerillo AG, Berti S, Candolfi P, Turchetti G. The cost-effectiveness of transcatheter aortic valve implantation: exploring the Italian National Health System perspective and different patient risk groups. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2021; 22:1349-1363. [PMID: 34019220 PMCID: PMC8558181 DOI: 10.1007/s10198-021-01314-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 04/28/2021] [Indexed: 05/09/2023]
Abstract
OBJECTIVES To assess the cost-effectiveness (CE) of transcatheter aortic valve implantation (TAVI) in Italy, considering patient groups with different surgical risk. METHODS A Markov model with a 1-month cycle length, comprising eight different health states, defined by the New York Heart Association functional classes (NYHA I-IV), with and without stroke plus death, was used to estimate the CE of TAVI for intermediate-, high-risk and inoperable patients considering surgical aortic valve replacement or medical treatment as comparators according to the patient group. The Italian National Health System perspective and 15-year time horizon were considered. In the base-case analysis, effectiveness data were retrieved from published efficacy data and total direct costs (euros) were estimated from national tariffs. A scenario analysis considering a micro-costing approach to estimate procedural costs was also considered. The incremental cost-effectiveness ratio (ICER) was expressed both in terms of costs per life years gained (LYG) and costs per quality adjusted life years (QALY). All outcomes and costs were discounted at 3% per annum. Univariate and probabilistic sensitivity analyses (PSA) were performed to assess robustness of results. RESULTS Over a 15-year time horizon, the higher acquisition costs for TAVI were partially offset in all risk groups because of its effectiveness and safety profile. ICERs were €8338/QALY, €11,209/QALY and €10,133/QALY, respectively, for intermediate-, high-risk and inoperable patients. ICER values were slightly higher in the scenario analysis. PSA suggested consistency of results. CONCLUSIONS TAVI would be considered cost-effective at frequently cited willingness-to-pay thresholds; further studies could clarify the CE of TAVI in real-life scenarios.
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Affiliation(s)
- V Lorenzoni
- Institute of Management, Scuola Superiore Sant'Anna, Pisa, Italy.
| | - G Barbieri
- Edwards Lifesciences Italia S.p.A, Milan, Italy
| | - F Saia
- Cardio-Thoracic-Vascular Department, RCCS University Hospital of Bologna, Policlinico S. Orsola, Bologna, Italy
| | - F Meucci
- Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - G L Martinelli
- Department of Cardiac Surgery, IRCCS MultiMedica Sesto San Giovanni, Milano, Italy
| | - A G Cerillo
- Division of Cardiac Surgery, Careggi University Hospital, Florence, Italy
| | - S Berti
- Fondazione C.N.R Regione Toscana G. Monasterio, Massa, Italy
| | - P Candolfi
- Edwards Lifesciences S.A., Nyon, Switzerland
| | - G Turchetti
- Institute of Management, Scuola Superiore Sant'Anna, Pisa, Italy
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