A budget impact analysis comparing transcatheter aortic valve implantation (TAVI) with surgical aortic valve replacement (SAVR) has concluded that the incremental annual cost of implementing TAVI in low-risk aortic stenosis patients is small, “making TAVR likely an affordable strategy”.
The research, published in the Canadia Journal of Cardiology, used a one-year time horizon to quantify the total cost of healthcare resource utilisation to initially treat low-risk AS patients and manage subsequent adverse events.
Derrick Y Tam (University of Toronto, Toronto, Canada) and colleagues estimated the total cost of care for various uptake rates of TAVI for a hypothetical centre with 100 low-risk AS patients. This showed that increasing the use of TAVI from baseline (10% of patients) to 50% and 70% had a small impact on the hospital budget (increases of 3% and 4.5% respectively).
Furthermore, in the first year of managing these patients, the upfront cost of the TAVI procedure was partially offset by the reduced cost of adverse events. The main contributors to the cost difference were TAVI intensive care unit (ICU) length of stay, new permanent pacemaker implantation rate, and total hospital length of stay. The average total cost of managing a low-risk AS patient for one year with TAVI (CAN$45,897) represents a nominal increase compared to SAVR (CAN$42,659).
“Although the cost-effectiveness of most transcatheter valve interventions is well studied, given the incremental costs associated with TAVR, the affordability from the hospital payer’s perspective was unknown,” said Tam. “As low-risk AS patients likely represent the majority of severe AS patients requiring intervention, understanding the cost impact of treating more patients with TAVI becomes critically important for health policy and resource planning.”
The researchers concluded that while survival rates do not vary, studies have shown that TAVI is associated with more rapid improvement in quality of life compared to SAVR, and that these findings persist to one year.
“As such, it is very reasonable that TAVI may be preferential to patients after a discussion of the risks and benefits. Similarly, the nominal incremental in hospital cost, can be offset by improved efficiencies in the system. Reduced overall length of hospital stay and ICU stay can relieve pressure on hospital bed capacity for optimizing resource use,” noted Tam.
In an accompanying editorial Fiona Clement and Derek (both University of Calgary, Calgary, Canada), welcome the study as an important contribution to support evidence-informed policy decisions about the adoption and balance between TAVI and SAVR. They point out that the true value of the work is making the model underlying the analysis openly available to decision-makers and researchers globally.
“This model represents a significant infrastructure. By making the model open access, the required investment of time and human resources need not be duplicated as decision-makers face similar questions about shifting from SAVR to TAVI. Further, the model can be responsive as science continues to develop,” they write.
However, Clement and Chew warn that costs alone should not drive the discussion of technology adoption and implementation. Recognition of other important factors should be taken into consideration, such as whether an intervention is immediately lifesaving; impact on quality of life; number of people eligible; vulnerable patient populations (e.g., children or the elderly); underlying baseline health; likelihood of the treatment being successful; and its impact on equality of access to therapy.
“Looking through this lens with respect to TAVI funding underscores the complexity of the decision-making process in the context of finite resources and the associated opportunity costs. These decisions will only become more challenging as innovation continues, often coming at increased cost,” Clement and Chew concluded.