Data from the US CoreValve High Risk study show that the incremental costs of transcatheter aortic valve implantation (TAVI) with the CoreValve device (Medtronic) in patients at high risk for surgery compared with surgical aortic valve replacement are acceptable from a US perspective. However, the value of TAVI with CoreValve in a high-risk population would be high if the index admission costs of the procedure were reduced
Speaking at the Transcatheter Cardiovascular Therapeutics (TCT) meeting (13–17 September, Washington, DC, USA), Matthew Reynolds (Economics and Quality of Life Research, Harvard Clinical Research Institute, Boston, USA) said that TAVI provides “substantial clinical benefits at acceptable incremental costs” for patients with severe aortic stenosis who are unsuitable for surgery, but added that there was “less consensus” about the cost-effectiveness of TAVI compared with surgical aortic valve replacement in patients at high risk for surgery. Therefore, the aim of the present study was to evaluate the costs of TAVI in this patient population.
Reynolds and his co-investigators used data from the as-treated population (747 patients) of the US CoreValve High Risk Trial, which recently showed that TAVI was associated with increased 12-month survival compared with surgery in a high-risk population. They reviewed patient-level lifetime projections of life expectancy, quality-adjusted life expectancy, and costs. The primary effectiveness measure was quality adjusted life years and the secondary measure was life years.
Reynolds noted that two key assumptions were made: that the cost of the CoreValve device was US$32,000 and there would be no further survival benefit with TAVI beyond 12 months.
Procedure duration, room time, total hospitalisation days, and total ventilation time were all significantly reduced with TAVI compared with surgical aortic valve replacement. However, the initial hospital costs were higher with TAVI—US$69,000 vs. US$58,000 for surgical aortic valve replacement (a difference of about US$11,000). Also, TAVI patients were estimated to gain 0.24 life years and 0.20 quality adjusted life years compared with surgical patients but the projected lifetime incremental cost-effectiveness ratio with TAVI was about US$67,000 per quality adjusted life year gained and $57,000 per life year gained. Reynolds said: “Results were slightly better among patients suitable for iliofemoral access (623 patients) at about US$55,000 per quality adjusted life year gained and $48,300 per life year gained and were less favourable for the non-iliofemoral patients (124 patients) at about $118,000 quality adjusted life year gained and US$98,000 per life year gained.” He added that the results in the non-iliofemoral group were “markedly uncertain” because of the small sample size.
Jeffrey Anderson (Veterans Affairs Salt Lake City Health Care System, Salt Lake City, USA) and others recently reported in the Journal of the American College of Cardiology that a procedure that costs between US$50,000 and US$150, 000 is of intermediate value while a procedure cost US$50,000 or less is of high value. According to Reynolds, a sensitivity analysis indicated that reducing the cost of the initial TAVI hospitalisations by US$2,000–US$4,000 per patient would lower the cost-effectiveness ratios for the procedure to less than US$50,000—meaning that “the value of TAVI compared with surgical aortic valve replacement in high-risk patients would become high”.
He concluded: “In this high-risk patient population, TAVI provided meaningful clinical benefits relative to surgical aortic valve replacement with incremental costs considered acceptable from a US perspective.”