Systematic review of the cost-effectiveness of transcatheter aortic valve implantation

Abstract

Depending on the ICER threshold selected, TAVI is potentially justified on both medical and economic grounds compared with medical therapy for patients deemed to be surgically inoperable. However, in the high-risk surgical patient cohort, the evidence is currently insufficient to economically justify the use of TAVI in preference to AVR.

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

“…134 Compared with SAVR in operable high surgical risk patients, evidence of cost-effectiveness of TAVI is much less consistent. 127,129,[134][135][136] In an intermediate-risk cohort with severe AS, in-hospital, follow-up, and total 1-year costs were all higher for TAVI than for SAVR. 137 The difference was mainly caused by the higher costs of the valve and was not compensated by the lower costs of blood products and hospital stay.…”

“…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.…”

Overuse of Cardiovascular Services

“…To this end, the cardiovascular community has taken the lead to provide incremental cost-effectiveness analysis in addition to clinical comparative effectiveness, especially among emerging, high-cost technology such as transcatheter aortic valve implantation and identified specific high-risk patient populations in whom the technology may not be cost effective. 68 Although it is apparent that clinicians respond to clinical trial data, CER findings, or economic analysis, it must be pointed out that a significant translational gap exists between evidence and practice. 69 To reduce overuse, it is first critical to develop specific and actionable measures of overuse, building on clear conceptual framework, sound scientific evidence, and consensus on the types of measures and their appropriate use.…”

Transcatheter Aortic Valve Replacement Indications Should Not Be Expanded to Lower-Risk and Younger Patients

“…57 The currently available data do not conclusively demonstrate that TAVR is incrementally costeffective compared with SAVR for high-risk surgical candidates because of the wide variability of incremental cost-effectiveness ratio values and probabilities of economic acceptability reported in different countries and reimbursement systems. 58 Six of 9 analyses reported an incremental cost-effectiveness ratio value that would have been deemed unacceptable with the use of a US $100 000 per quality-adjusted life year gained threshold, and 7 would have been deemed unacceptable with the use of a US $50 000 per quality-adjusted life year gained threshold. In the United States, the total costs of TAVR and SAVR were generally similar because the higher device-and procedure-related expenses for TAVR were offset by the comparatively greater costs of hospitalization after SAVR.…”

“…In the United States, the total costs of TAVR and SAVR were generally similar because the higher device-and procedure-related expenses for TAVR were offset by the comparatively greater costs of hospitalization after SAVR. 58 If cost-effectiveness in a (surgical) high-risk population cannot be demonstrated, it can hardly be expected in a low -risk group of patients. low-risk patients undergoing SVR have a short (if any) stay in the intensive care unit and can usually be discharged shortly after surgery, effectively decreasing the costs for hospitalization.…”