An analysis of the cost-effectiveness of transcatheter mitral valve repair for people with secondary mitral valve regurgitation in the UK

Abstract

Introduction and aims A proportion of chronic heart failure (CHF) patients will experience regurgitation secondary to ventricular remodelling in CHF, known as functional mitral (MR) or tricuspid (TR) regurgitation. Its presence adversely impacts prognosis and healthcare utilisation in CHF patients. The advent of interventional devices for both atrioventricular valves modifies both aspects. We present an economic model structure suitable for comparing interventions used in MR and TR, and assess the cost-effectiveness of transcatheter mitral valve repair (TMVr) plus guideline directed medical therapy (GDMT) compared with GDMT alone in people with MR. Methods An economic model with a lifetime time horizon was developed based on extrapolated survival data and using New York Heart Association classifications to describe disease severity in people with functional MR at high risk of surgical mortality or deemed inoperable. Cost and utility values (describing health related quality of life) were assigned to patients dependent on their disease severity. The analysis was conducted from a UK National Health Service perspective. An incremental cost per additional quality-adjusted life year (QALY) was estimated, and sensitivity (one-way and probabilistic) and scenario analyses conducted. Results and conclusions Compared with GDMT, the use of TMVr results in an additional 1.07 QALYs and an increase in costs of £32,267 per patient over a lifetime time horizon. The estimated incremental cost A c c e p t e d M a n u s c r i p t per QALY gained is £30,057 and would therefore be on the threshold of cost-effectiveness at £30,000 per quality adjusted life year. Thus, from a UK reimbursement perspective, in patients with severe functional MR who are at high risk of surgical mortality or deemed inoperable with conventional surgery, TMVr plus medical therapy is likely to represent a cost-effective treatment option compared with GDMT alone. The choice of device (MitraClip or PASCAL) will need to be confirmed once further clinical data are reported.

Cost-effectiveness of transcatheter edge-to-edge repair in secondary mitral regurgitation: is confirmation needed?

“…The US analysis6 estimated an increase in life expectancy of 1.13 years and in QALYs of 0.82, similar with the results of the NICE guideline analysis which found TEER to increase life expectancy by 1.18 years and QALYs by 0.69. Additionally, a previously published cost-effectiveness analysis based on COAPT and conducted from the UK NHS perspective7 reported an incremental cost-effectiveness ratio of £30 057 per QALY gained, which is very close to the NICE guidelines analysis result (£30 175).…”

“…The analysis performed by Cohen et al reports a very low incremental cost-effectiveness ratio, considerably lower than the incremental cost-effectiveness ratio reported by Shore et al 7 and by the NICE guidelines . 4 This low incremental cost-effectiveness ratio is the result of using costs that seemed to have been chosen from the lowest available estimates, without providing any explanation or rationale, despite referring to a COAPT-like population with heart failure, advanced age and multiple comorbidities (table 1).…”

“…This cost would have been similar with the CtE micro-cost analysis derived central estimation of £12 760, which was also used in the health economic model that informed the NICE guidelines. Furthermore, this cost would have compared relatively well also with the estimated cost of the procedure of £11 208 from the micro-cost analysis published by Shore et al 7…”

“…The cost of high-cost tariff devices used in health economic evaluations is the supply chain cost, which for the TEER device is £16 500. This supply chain cost was used in the Shore et al cost-effectiveness analysis,7 however, the Cohen et al analysis used a lower device cost (£16 218) of undisclosed provenience.…”

“…The authors do not appear to have consulted the two UK micro-cost analyses available to verify the appropriateness of the costs they collected from national sources. These UK micro-cost analyses are the NHS England CtE3 and the Shore et al cost-effectiveness analysis 7. Cohen et al used the English tariffs and the Payment by Result (PbR) tariffs , not appropriate for a cost-effectiveness analysis performed from a UK NHS perspective.…”