Estimating the additional costs per life saved due to transcatheter aortic valve replacement: a secondary data analysis of electronic health records in Germany

Abstract

Aortic stenosis (AS) is the most common valvular heart disease, with a dismal prognosis when untreated. Recommended therapy is surgical (SAVR) or transcatheter (TAVR) aortic valve replacement. Based on a retrospective cohort of isolated SAVR and TAVR procedures performed in Germany in 2015 (N = 17,826), we examine the impact of treatment selection on in-hospital mortality and total in-hospital costs for a variety of at-risk populations. Since patients were not randomized to the two treatment options, the two endpoints in-hospital mortality and reimbursement are analyzed using logistic and linear regression models with 20 predefined patient characteristics as potential confounders. Incremental cost-effectiveness ratios were calculated as a ratio of the risk-adjusted reimbursement and mortality differences with 95% confidence intervals obtained by Fieller's theorem. Our study shows that TF-TAVR is more costly that SAVR and that cost differences between the procedures vary little between patient groups. Results regarding in-hospital mortality are mixed. SAVR is the predominant procedure among younger patients. For patients older than 85 years or at intermediate and higher pre-operative risk TF-TAVR seems to be the treatment of choice. Incremental cost-effectiveness ratios (ICER) are most favorable for patients older than 85 years (ICER €154,839, 95% CI €89,163-€302,862), followed by patients at higher pre-operative risk (ICER €413,745, 95% CI €258,027-€952,273). A hypothetical shift from SAVR towards TF-TAVR among patients at intermediate pre-operative risk is associated with a less favorable ICER (€1,486,118, 95% CI €764,692,323), as the risk-adjusted mortality benefit is relatively small (− 0.97% point), while the additional reimbursement is still eminent (+€14,464). From a German healthcare system payer's perspective, the additional costs per life saved due to TAVR are most favorable for patients older than 85 and/or at higher pre-operative risk.

The transcatheter aortic valve implantation: an assessment of the generalizability of the economic evidences following a systematic review

“…All studies (8;20–49) report the ICER. In twenty-nine studies, the ICER was expressed in terms of cost per QALY and in one as the ratio between the risk-adjusted reimbursement and the difference in mortality.…”

“…The characteristics of the study sample are well detailed in twenty-one documents (20;21;26;27;30;32;33;35–45;49) documents. In these articles, information was gathered by age, sex, risk, and procedure.…”

“…In all documents (8;20–49), the point of view of the third-party payer was considered. Of these, two studies (24;46) also considered the societal perspective.…”

“…Twenty-six documents (8;21;22;24–26;28;30–48) reported both a quantitative and qualitative analysis. The other five articles (20;23;27;29;49) presented only a quantitative analysis. The studies that performed the qualitative analysis compared their study with other studies to show the differences in cost-effectiveness analysis between different countries.…”

Use and Outcomes of Acute Treatment Strategies in Patients with Severe Aortic Valve Stenosis

“…The shift towards TAVR is still associated with an increase of in-hospital costs [ 30 ]. The present study confirms that treatment costs were highest in the TAVR group in emergency settings.…”