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

The Impact of Transcatheter Aortic Valve Implantation on Health Care Costs and Clinical Outcomes Based on Frailty Risk: A Nationwide Cohort Analysis

BACKGROUND

Transcatheter aortic valve implantation (TAVI) is preferred for treating severe aortic stenosis in older, frail populations, yet the impact of frailty on economic and clinical outcomes of TAVI is not well studied.

METHODS

This retrospective cohort study included 2175 TAVI patients from 2015 to 2019, using Korea's National Health Insurance Service database, stratifying patients into low, intermediate, and high-frailty groups, using the Hospital Frailty Risk Score (HFRS). Health care costs, admissions, and total length of hospitalization were analyzed using Wilcoxon-rank test 12 months pre- and post-TAVI. Composite endpoint of death, stroke, and major bleeding, with individual outcomes, were compared using χ2 tests and Kaplan-Meier analysis.

RESULTS

Mean age was 80.2 years, and 47.3% were male; 747 (34.3%) were low frailty, 1159 (53.3%) were moderate frailty, and 269 (12.4%) were high frailty. After TAVI, medical costs decreased in the intermediate- (pre-TAVI: 2,269,000 KRW [$1668 USD], post-TAVI: 1,607,000 KRW [$1181 USD]; P < 0.001) and high-frailty groups (pre-TAVI: 3,949,000 KRW [$2904 USD], post-TAVI: 2,188,000 KRW [$1609 USD]; P < 0.001). All frailty groups had shorter length of hospital stay post-TAVI (26 to 21 days in the low-frailty, 44 to 31 days in the intermediate-frailty, and 65 to 41 days in the high-frailty group; all P <0.001). The composite outcome was higher in the frailer groups (27.8% in the low-frailty vs 31.5% in the intermediate-frailty vs 37.9% in the high-frailty group; P = 0.008). All groups showed comparable rates of cardiovascular death, stroke, or bleeding.

CONCLUSIONS

TAVI is clinically viable and cost-saving treatment option for frail patients with severe aortic stenosis.

A Systematic Review and Statistical Analysis of Factors Influencing the Cost-Effectiveness of Transcatheter Aortic Valve Implantation for Symptomatic Severe Aortic Stenosis

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.

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

INTRODUCTION

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Value-Based Care: A Review of Key Challenges and Opportunities Relevant to Medical Technology Innovators

Developed countries struggle with high healthcare spending, and cost is often cited as a barrier to the introduction of new patient care technologies. The core objective of this review article is to help familiarize medical technology innovators with trends in the health economic environment and the implications for the adoption of new technologies. We review and discuss this topic in language accessible to medical technology innovators. We assess macrolevel developments in healthcare spending and highlight measures already taken to control spending. We discuss practical implications for anyone involved in healthcare innovation. Two observations are central to this discussion: (1) the U.S. spends significantly more on healthcare per capita than any other developed country; (2) across developed countries, healthcare spending has risen steadily over the past two decades. Nevertheless, higher spending has not always led to improvements in health. As a result, innovators need to be prepared to navigate an outcomes-oriented and value-based environment that is being defined by the emerging requirements of various healthcare stakeholders. Practically, new products should aim to improve health outcomes at a cost deemed “good value” and/or reduce cost for one or multiple stakeholders. Opportunities also exist for tools that enable cost/outcomes tracking, which will help demonstrate value to providers, insurers, and patients.

Comparison of Causes and Associated Costs of 30-Day Readmission of Transcatheter Implantation Versus Surgical Aortic Valve Replacement in the United States (A National Readmission Database Study)

Our current knowledge about comparative differences in 30-day readmissions and the impact of readmissions on overall costs after transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR) is largely derived from clinical trials. The objectives of this study were to compare readmissions and costs for TAVI and SAVR in a nationally representative population-based sample. The Healthcare Cost and Utilization Project's National Readmission Database was used for the study. Hierarchical multivariable regression analyses were used to examine differences in the propensity score 1:1 matched cohort. The matched cohort included 4,682 patients who survived index procedures done from January through November 2013. Compared with SAVR, the rate of 30-day readmission was not significantly different for endovascular TAVI (16% vs 18%; p = 0.19); and was higher for the transapical TAVI (22% vs 17%; p <0.01) group. The 30-day cumulative costs were higher for the 2 endovascular TAVI ($51,025 vs $46,228; p = 0.03) and transapical TAVI ($59,575 vs $45,792; p <0.01). In multivariable analyses, the risk of 30-day readmission was similar for endovascular TAVI (odds ratio [OR] 0.93; 95% confidence interval [CI] 0.78 to 1.12) and was 27% higher for transapical TAVI (OR 1.27; 95% CI 1.02 to 1.57). Cumulative costs (index plus readmission costs) were 13% (β 0.13; 95% CI 0.10 to 0.15) and 19% (β 0.19; 95% CI 0.16 to 0.23) higher for the endovascular TAVI and transapical TAVI, respectively. In conclusion, the rate of readmissions was similar for endovascular TAVI and SAVR but the costs were 26% higher for TAVI than for SAVR.

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

OBJECTIVE

To review the evidence on the cost-effectiveness of heart valve implantations generated by decision analytic models and to assess their methodological quality.

METHODS

A systematic review was performed including model-based cost-effectiveness analyses of heart valve implantations. Study and model characteristics and cost-effectiveness results were extracted and the methodological quality was assessed using the Philips checklist.

RESULTS

Fourteen decision-analytic models regarding the cost-effectiveness of heart valve implantations were identified. In most studies transcatheter aortic valve implantation (TAVI) was cost-effective compared to standard treatment (ST) in inoperable or high-risk operable patients (ICER range 18,421-120,779 €) and in all studies surgical aortic valve replacement (SAVR) was cost-effective compared to ST in operable patients (ICER range 14,108-40,944 €), but the results were not consistent on the cost-effectiveness of TAVI versus SAVR in high-risk operable patients (ICER range: dominant to dominated by SAVR). Mechanical mitral valve replacement (MVR) had the lowest costs per success compared to mitral valve repair and biological MVR. The methodological quality of the studies was moderate to good.

CONCLUSION

This review showed that improvements can be made in the description and justification of methods and data sources, sensitivity analysis on extrapolation of results, subgroup analyses, consideration of methodological and structural uncertainty, and consistency (i.e. validity) of the models. There are several opportunities for future decision-analytic models of the cost-effectiveness of heart valve implantations: considering heart valve implantations in other valve positions besides the aortic valve, using a societal perspective, and developing patient-simulation models to investigate the impact of patient characteristics on outcomes.

Reducing the Global Burden of Cardiovascular Disease, Part 2: Prevention and Treatment of Cardiovascular Disease

In this second part of a 2-part series on the global burden of cardiovascular disease, we review the proven, effective approaches to the prevention and treatment of cardiovascular disease. We specifically review the management of acute cardiovascular diseases, including acute coronary syndromes and stroke; the care of cardiovascular disease in the ambulatory setting, including medical strategies for vascular disease, atrial fibrillation, and heart failure; surgical strategies for arterial revascularization, rheumatic and other valvular heart disease, and symptomatic bradyarrhythmia; and approaches to the prevention of cardiovascular disease, including lifestyle factors, blood pressure control, cholesterol-lowering, antithrombotic therapy, and fixed-dose combination therapy. We also discuss cardiovascular disease prevention in diabetes mellitus; digital health interventions; the importance of socioeconomic status and universal health coverage. We review building capacity for conduction cardiovascular intervention through strengthening healthcare systems, priority setting, and the role of cost effectiveness.

Improving the Methods for the Economic Evaluation of Medical Devices

Medical devices (MDs) have distinctive features, such as incremental innovation, dynamic pricing, the learning curve and organisational impact, that need to be considered when they are evaluated. This paper investigates how MDs have been assessed in practice, in order to identify methodological gaps that need to be addressed to improve the decision-making process for their adoption. We used the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist supplemented by some additional categories to assess the quality of reporting and consideration of the distinctive features of MDs. Two case studies were considered: transcatheter aortic valve implantation (TAVI) representing an emerging technology and implantable cardioverter defibrillators (ICDs) representing a mature technology. Economic evaluation studies published as journal articles or within Health Technology Assessment reports were identified through a systematic literature review. A total of 19 studies on TAVI and 41 studies on ICDs were analysed. Learning curve was considered in only 16% of studies on TAVI. Incremental innovation was more frequently mentioned in the studies of ICDs, but its impact was considered in only 34% of the cases. Dynamic pricing was the most recognised feature but was empirically tested in less than half of studies of TAVI and only 32% of studies on ICDs. Finally, organisational impact was considered in only one study of ICDs and in almost all studies on TAVI, but none of them estimated its impact. By their very nature, most of the distinctive features of MDs cannot be fully assessed at market entry. However, their potential impact could be modelled, based on the experience with previous MDs, in order to make a preliminary recommendation. Then, well-designed post-market studies could help in reducing uncertainties and make policymakers more confident to achieve conclusive recommendations. © 2017 The Authors. Health Economics published by John Wiley & Sons, Ltd.

HEALTH TECHNOLOGY ASSESSMENTS REPORTING COST-EFFECTIVENESS OF TRANSCATHETER AORTIC VALVE IMPLANTATION

Objectives: Made available since 2002, transcatheter aortic valve implantation (TAVI) is a minimally invasive new intervention which can provide significant survival improvement to patients with aortic stenosis. However, TAVI is expensive and currently not reimbursed by many governments. Some governments and institutions have been conducting health technology assessments (HTAs) to inform their reimbursement decisions. The aim of the present study is to review HTAs that have relied on a cost-effectiveness analysis to inform reimbursement decisions of TAVI.

Methods: A systematic literature review was conducted among published literature as well as reports released by HTA agencies. Predetermined inclusion and exclusion criteria, following the Preferred Reporting System for Systematic Reviews and Meta-Analysis guidelines, were used to select relevant HTAs. The selected papers were assessed against the Consolidated Health Economic Evaluation Reporting Standards.

Results: HTAs on TAVI from three countries were available for this review: Canada, Belgium, and the United Kingdom. All three HTAs used the Placement of Aortic Transcatheter Valve (PARTNER) trial data with Markov models to estimate the incremental cost effectiveness ratio. The three HTAs recommended conditional reimbursement for TAVI for otherwise inoperable patients. The HTAs did not use clear methods to estimate the health-related utility which ultimately affected their cost-effectiveness results. The UK HTA showed the best value for money (US$20,416 per quality-adjusted life-year).

Conclusion: All studies found TAVI to be more costly and less effective for high-risk patients suitable for surgery, whereas TAVI was consistently found to be cost effective for otherwise inoperable patients.

Quality of life among elderly patients undergoing transcatheter or surgical aortic valve replacement- a model-based longitudinal data analysis

Background

Quality of life (QoL) measurements reported in observational studies are often biased, since patients who failed to improve are more likely to be unable to respond due to death or impairment. In order to observe the development of QoL in patients close to death, we analyzed a set of monthly QoL measurements for a cohort of elderly patients treated for aortic valve stenosis (AS) with special consideration of the effect of distance to death.

Methods

QoL in 169 elderly patients (age ≥ 75 years), treated either with transcatheter aortic valve replacement (TAVR; n = 92), surgical aortic-valve replacement (n = 70), or drug-based therapy (n = 7), was evaluated using the standardized EQ-5D questionnaire. Over a two-year period, patients were consulted using monthly telephone interviews or outpatient visits, leading to a total of 2463 time points at which QoL values, New York Heart Association (NYHA) Functional Classification and their status of assistance were assessed. Furthermore, post-procedural clinical events and complications were monitored. Linear and ordered logistic regression analyses with random intercept were carried out, taking into account overall trends and distance to death.

Results

QoL measures decreased slightly over time, were temporarily impaired at month 1 after the initial episode of hospitalization and decreased substantially at the end of life with a measurable effect starting at the sixth from last follow-up (month) before death. Many clinical complications (bleeding complications, stroke, acute kidney injury) showed an impairment of QoL measurements, but the inclusion of lagged variables demonstrated medium term (three months) QoL impairments for access site bleeding only. All other complications are associated with event-related impairments that decreased dramatically at the second and third follow-up interviews (month) after event.

Conclusions

Distance to death shows clear effects on QoL and should be taken into account when analyzing QoL measures in the elderly patients treated for aortic valve stenosis.

Trial registration

German Clinical Trial Register Nr. DRKS00000797

The cost effectiveness of transesophageal echocardiography for pediatric cardiac surgery: a systematic review

BACKGROUND

Intraoperative transesophageal echocardiography (ITEE) for pediatric cardiac surgery has been described as clinically efficacious and cost-effective. There are a small number of publications supporting these claims.

AIMS

The objectives were to assess the quality of the research, the variability of results across studies and, if possible, to make a consensus statement based on the results.

METHODS

In March 2015, a systematic search of MEDLINE and MEDLINE In-Process, EMBASE, and the National Health Service Economic Evaluation Database was performed. The search was supplemented with a review of Health Technology Assessment reports through the Centre for Reviews and Dissemination database. English language articles including any quantitative economic evaluation were included. The quality of each study was assessed using the British Medical Journal economic evaluation quality checklist. Data extracted included the main outcomes from each study, study methodologies, itemized costs, sensitivity ranges, biases, and delayed reoperation prevented with ITEE. When possible, a cost-savings per ITEE was calculated to facilitate comparison across studies and used to create a synthesis of the results.

RESULTS

Seven studies met the inclusion criteria; of these, five were included in the synthesis of results. The cost-savings per ITEE ranged from $194 to $4910 with a mean of $1930 (95%CI: $845 to $3015) (2015 USD). Prevented delayed reoperation rates using ITEE ranged from 2.8% to 10%. Earlier studies were of poorer quality (scores 8-17) and more recent studies were of higher quality (scores 22-25). Methodologies used were either retrospective chart reviews (57%) or prospective observational studies (43%) with a range of approaches to estimate costs.

CONCLUSION

ITEE for pediatric cardiac surgery is effective and cost-saving. This is a validation of the current practice patterns. These finding may influence the expansion of the use of this technology.

Transcatheter aortic valve replacement in nonagenarians: early and intermediate outcome from the OBSERVANT study and meta-analysis of the literature

The purpose of this study was to evaluate the outcome of nonagenarians after transcatheter aortic valve replacement (TAVR) from the OBSERVANT study and to pool the results of the literature on this topic. Aortic stenosis is the most common acquired valvular heart disease in the Western countries, and its prevalence is linked to the phenomenon of population aging. TAVR can be considered as a wise approach to treat nonagenarians, but data on its safety and effectiveness are scarce. Data on 80 patients aged >90 years who underwent TAVR from OBSERVANT study were analyzed. A systematic review and meta-analysis of published data were performed. Thirty-day mortality in the OBSERVANT series was 6.3 %. None of these patients experienced stroke. Permanent pacemaker implantation was necessary in 20 % of patients. Paravalvular regurgitation was observed in 57.5 %. Survival at 1, 2, and 3 years was 79.6, 71.9, and 61.5 %. Ten series provided data on 1227 nonagenarians who underwent TAVR. Pooled 30-day mortality rate was 7.1 %, stroke 2.8 %, vascular access complication 8.8 %, and permanent pacemaker implantation 10.6 %. Paravalvular regurgitation was observed in 60.1 % of patients. Pooled 1-, 2-, and 3-year survival rates were 79.2, 68.2, and 55.6 %. Transapical TAVR was associated with a significantly higher risk of early mortality compared with transfemoral TAVR. The results of OBSERVANT study and aggregate data meta-analysis suggest that in nonagenarians, TAVR is associated with low postoperative morbidity and excellent intermediate survival. Transapical TAVR in these very elderly is associated with high postoperative mortality.

Transcatheter Aortic Valve Implantation in Lower-Risk Patients With Aortic Stenosis

Transcatheter aortic valve implantation underwent progressive improvements until it became the default therapy for inoperable patients, and a recommended therapy in high-risk operable patients with symptomatic severe aortic stenosis. In the lower-risk patient strata, a currently costly therapy that still has important complications with questionable durability is competing with the established effective and still-improving surgical replacement. This report tries to weigh the clinical evidence, the recent technical improvements, the durability, and the cost-effectiveness claims supporting the adoption of transcatheter aortic valve implantation in intermediate-low risk patients. The importance of appropriate patients’ risk stratification and a more comprehensive approach to estimate that risk are also emphasized in the present report.

Aortic Valve Gradient and Clinical Outcome in Patients Undergoing Transcatheter Aortic Valve Implantation for Severe Aortic Stenosis

Objectives: To explore the relation between the baseline aortic valve gradient (AVG) as a continuous variable and clinical outcomes following transcatheter aortic valve implantation (TAVI) in general and specifically in patients with high-gradient aortic stenosis (AS). Methods: We reviewed 317 consecutive patients who underwent TAVI at our institution. We investigated the relation between AVG as a continuous/categorical variable and outcome among all patients and in patients without low-flow low-gradient AS, using the Cox proportional hazard model adjusting for multiple prognostic variables. Results: Patients had a peak AVG of 79.9 ± 22.8 mm Hg (mean 50.5 ±15.7). During a mean follow-up of 2.7 years, AVG was inversely associated with mortality and mortality or cardiac hospitalization. Every 10-mm-Hg increase in peak AVG was associated with 18% reduction in mortality (p = 0.003) and 19% reduction in mortality/cardiac hospitalization (p < 0.001). Every 10-mm-Hg increase in mean AVG was associated with a 24% reduction in both outcomes (p = 0.005 and p < 0.001). Subgroup analysis of patients with left-ventricular ejection fraction >40% or peak AVG >64 mm Hg yielded similar results. Conclusions: Mean and peak baseline AVGs are directly associated with improved outcomes after TAVI; AVG can be used to select the patients most likely to benefit from TAVI.

Cost effectiveness of transcatheter aortic valve replacement compared with medical management or surgery for patients with aortic stenosis

BACKGROUND

In the symptomatic patient, severe aortic stenosis (AS) has an extremely adverse prognosis in the absence of valve replacement, inevitably leading to deterioration of heart function, heart failure, and death. However, many patients with severe AS, advanced age, and comorbid disease may die with AS rather than from AS. While the results of surgical aortic valve replacement (SAVR) are extremely favorable, this technique is not always possible because of either local- or patient-level contraindications. Over the last decade, transcatheter aortic valve replacement (TAVR) has emerged as a new treatment strategy for selected patients with AS. It has now become the standard of care for extremely high-risk (inoperable) patients with AS, and is an appropriate alternative to surgery in high-risk but operable patients. However, whether this intervention is a cost-effective use of resources is open to question

AIM

The aim of this review was to assess the results and quality of the economic evaluations in the current literature and to identify the drivers of cost effectiveness.

METHODS

We performed an electronic data search using four different electronic databases, selecting all studies that included cost-effectiveness data for TAVR compared with either medical management or surgery. Sixteen studies were evaluated for a qualitative and quantitative assessment.

RESULTS

The quality of the cost-effectiveness analyses (CEAs) were generally sufficient. In contrast, we found an extreme heterogeneity of input assumptions with consequent difficulties to generalize the conclusions. However, in the population of patients with severe symptomatic AS and a prohibitive surgical risk, TAVR generally represents a good choice, with incremental costs that are well balanced by the great benefit in terms of quality of life and survival. Nevertheless, the cost effectiveness of this procedure in the real world, particularly in patients with high healthcare costs from other comorbid conditions, may be less favorable. In AS patients with high (but not prohibitive) surgical risk, the choice between TAVR and SAVR is still debatable. Both procedures are comparable in terms of efficacy and safety but the evidence is inconclusive from an economic point of view.

CONCLUSIONS

On the basis of this review, it was ascertained that the details of risk evaluation and patient selection will be critical in understanding how improvements in survival can be used to target the use of TAVR to ensure the cost-effective and sustainable use of resources.