A cost-utility analysis of transcatheter aortic valve implantation in Belgium: focusing on a well-defined and identifiable population

Abstract

BackgroundPatients with severe aortic stenosis and coexisting non-cardiac conditions may be at high risk for surgical replacement of the aortic valve or even be no candidates for surgery. In these patients, transcatheter aortic valve implantation (TAVI) is suggested as an alternative. Results of the PARTNER (Placement of AoRTic TraNscathetER Valve) trial comparing the clinical effectiveness of TAVI with surgical valve replacement and standard therapy were published. The authors assessed the cost-effectiveness of TAVI in Belgium.MethodsA Markov model of incremental costs, effects (survival and quality of life) and incremental cost-effectiveness of TAVI was developed. The impact on survival, number of events and quality of life was based on the PARTNER trial. Costs per event were context specific.ResultsIn high-risk operable patients, even if the minor differences in 30-day and 1-year mortality are taken into account, the incremental cost-effectiveness ratio (ICER) remains on average above €750 000 per quality-adjusted life-year (QALY) gained (incremental cost: €20 400; incremental effect: 0.03 QALYs). In inoperable patients, an ICER of €44 900 per QALY (incremental cost: €33 200; incremental effect: 0.74 QALYs) is calculated, including a life-long extrapolation of the mortality benefit. This result was sensitive to the assumed time horizon. The subgroup of anatomically inoperable patients had better outcomes than medically inoperable patients, with ICERs decreasing more than €10 000/QALY.ConclusionsIt is inappropriate to consider reimbursement of TAVI for high-risk operable patients. Reimbursing TAVI in inoperable patients in essence is a political decision. From an economic perspective, it would be prudent to first target patients that are inoperable because of anatomical prohibitive conditions. In the search for evidence, the authors identified non-published negative results from a randomised controlled TAVI trial. The study sponsor should be more willing to share this information to allow balanced evaluations and policy recommendations. Payers should require these data before taking reimbursement decisions.

The impact of post-procedural complications on reimbursement, length of stay and mechanical ventilation among patients undergoing transcatheter aortic valve implantation in Germany

“…These data are rarely presented and we consider the results to be of special relevance to economic modelling analyses set in Germany, where the various outcomes of our study may be used as inputs [2][3][4][5][6]22].…”

“…Evidence for the cost-effectiveness of TAVR generally agrees that TAVR is competitive compared to standard medical therapy, with multiple studies finding the cost-benefit ratio of TAVR to be within the acceptable range for the healthcare systems examined [2][3][4][5], with one notable exception from Belgium [6]. Comparisons of TAVR and SAVR have been less conclusive, possibly due at least in part to a lack of strong clinical data underpinning the analyses, since accurate published cost data for TAVR procedures is somewhat limited due to difficulties in collecting data from most systems [7].…”

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

“…126 TAVI was shown to be cost-effective when compared with conservative treatment in symptomatic patients who are not candidates for SAVR, [127][128][129][130][131][132] and it was even more cost-effective in the subgroup of anatomically inoperable than medically inoperable patients 133 and in those with a lower burden of noncardiac comorbidities. 134 Compared with SAVR in operable high surgical risk patients, evidence of cost-effectiveness of TAVI is much less consistent.…”

The Cost-Effectiveness of Transcatheter Aortic Valve Replacement for Nonsurgical Candidates

“…Prior studies have reported incremental cost-effectiveness ratios ranging from £16 100 6 to $61 900 per QALY gained, 7 with intermediate values reported in the US dollars, 8 Canadian dollars, 9,10 and Euros. 11 Thus, the current study has reached a somewhat more pessimistic view of the cost-effectiveness of TAVR than a number of other independent analyses that were largely derived from the same data set.…”

“…TAVR may be a much better value for patients who are inoperable for technical reasons rather than because of severe, complex comorbidity 11 because the life expectancy gain in these relatively lower risk patients is greater. 3 Researchers will need to continue trying to define patient groups for whom TAVR is truly futile to better inform patients who are considering the procedure and to facilitate the decision making of heart teams.…”