Cost-Effectiveness of Transcatheter Aortic Valve Implantation in Intermediate and Low Risk Severe Aortic Stenosis Patients in Singapore

Abstract

Introduction: Singapore has the world’s second most efficient healthcare system while costing less than 5% GDP. It remains unclear whether transcatheter aortic valve implantation (TAVI) is cost-effective for treating intermediate-low risk severe aortic stenosis (AS) patients in a highly efficient healthcare system. Materials and Methods: A two-phase economic model combining decision tree and Markov model was developed to assess the costs, effectiveness, and the incremental cost-effectiveness ratio (ICER) of transfemoral (TF) TAVI versus surgical aortic valve replacement (SAVR) in intermediate-low risk patients over an 8-year time horizon. Mortality and complications rates were based on PARTNER 2 trial cohort A and Singapore life table. Costs were mainly retrieved from Singapore National University Health System database. Health utility data were obtained from Singapore population based on the EuroQol-5D (EQ-5D). A variety of sensitivity analyses were conducted. Results: In base case scenario, the incremental effectiveness of TF-TAVI versus SAVR was 0.19 QALYs. The ICER of TF-TAVI was S$33,833/QALY. When time horizon was reduced to 5 years, the ICER was S$60,825/QALY; when event rates from the propensity analysis was used, the ICER was S$21,732/QALY and S$44,598/QALY over 8-year and 5-year time horizons, respectively. At a willingness to pay threshold of S$73,167/QALY, TF-TAVI had a 98.19% probability of being cost-effective after 100,000 simulations. The model was the most sensitive to the costs of TF-TAVI procedure. Conclusion: TF-TAVI is a highly cost-effective option compared to SAVR for intermediate-low risk severe AS patients from a Singapore healthcare system perspective. Increased procedure experience, reduction in device cost, and technology advance may have further increased the cost-effectiveness of TF-TAVI per scenario analysis. Keywords: Surgical aortic valve replacement, Quality of life, Transfemoral TAVI, Reimbursement

Transcatheter Aortic Valve Implantation for Patients with Severe Symptomatic Aortic Stenosis

“…In addition to those identified in the systematic reviews, 8 relevant economic evaluations 22,24,[27][28][29][30][31][32] were identified. All 8 economic evaluations 22,24,[27][28][29][30][31][32] were conducted as cost-utility analyses and incorporated Markov models that included between 2 31 and 9 24,28,29 health states. The time horizons were 8 years, 32 15 years, 24,[27][28][29] and lifetime.…”

“…All 8 economic evaluations 22,24,[27][28][29][30][31][32] were conducted as cost-utility analyses and incorporated Markov models that included between 2 31 and 9 24,28,29 health states. The time horizons were 8 years, 32 15 years, 24,[27][28][29] and lifetime. 22,30,31 The analysis by Himmels 31 used a decision tree model for the initial 2 years of analysis that fed into a Markov model with 1-year cycles with 2 states: alive and dead.…”

“…Kuntjoro et al (2020) 32 used a 2-phase economic model that had a decision tree model for the initial 30 days, followed by a long-term Markov model with 1-year cycles. The analysis was conducted using an 8-year horizon from the perspective of the National University Health System in Singapore.…”

“…These comprised 3 HTAs (each included a systematic review [22][23][24] ; 2 included primary economic evaluations 22,24 ), 2 systematic reviews, 25,26 and 6 economic evaluations. [27][28][29][30][31][32] Appendix 1 presents the PRISMA 33 flow chart of the study selection. Additional references of potential interest are provided in Appendix 6.…”

“…Three relevant HTAs (which included 3 systematic reviews [22][23][24] and 2 de novo economic evaluations 22,24 ), 2 systematic reviews, 25,26 and 6 economic evaluations [27][28][29][30][31][32] were included in this review. The components of the identified HTAs that are relevant to this report (i.e., 3 systematic reviews and 2 economic evaluations) will be described individually, as much of the other information contained in these HTAs is beyond the scope of the current report.…”