Economic Implications of Transcatheter Aortic Valve Replacement in Patients at Intermediate Surgical Risk
Authors: Matthew R. Reynolds, Suzanne J. Baron, David J. Cohen
Journal: Circulation (2016)

opulation aging and other factors are propelling healthcare spending on a perpetually increasing trajectory.More than ever, we must carefully assess the economic impact of adopting new medical technologies into clinical practice.Recently, transcatheter aortic valve replacement (TAVR) has emerged as a remarkable advance in the treatment of aortic stenosis.2][3] As the role of TAVR is now considered for intermediate-risk patients, questions about value must be asked and answered again.To understand the cost-effectiveness of TAVR in intermediate-risk patients, it is helpful to consider the lessons learned in higher-risk patients.First, it is apparent that the major offsets for the increased technology cost of TAVR in comparison with surgical aortic valve replacement (SAVR) are decreased hospital length of stay (LOS) and a reduced need for postacute rehabilitation services.With TAVR prices currently in excess of $30 000 per device in the United States (in comparison with ≈$5000 per surgical valve), reductions in LOS must be quite large for TAVR to pay for itself.If the costs of TAVR are higher than SAVR, the cost-effectiveness of TAVR from a societal perspective is strongly affected by the presence or absence of a mortality benefit with TAVR.In the absence of a survival difference, the advantages of TAVR relative to SAVR consist primarily of faster recovery, avoidance of certain complications, and improved quality of life, which is transient.In health economic terms, these benefits result in only small (<0.10) gains in quality-adjusted life-years.When quality-adjusted life-year gains are small, incremental costs must also be small for the ratio between costs and benefits (the incremental cost-effectiveness ratio [ICER] to be favorable.In contrast, when even a modest survival benefit is present, the quality-adjusted life-year gains become larger and the ICER can remain favorable despite substantially higher costs.To illustrate these concepts, we have plotted a hypothetical ICER for TAVR versus SAVR across a range of reductions in initial hospital LOS, with and without a survival advantage for TAVR (Figure).When hospital costs are close to neutral, TAVR can provide excellent value, even in the absence of a survival benefit, simply by speeding recovery and improving short-term quality of life.However, if the incremental costs of TAVR are moderately large (eg, >$10 000 per patient), then ICERs are quite high and unfavorable in the absence of a survival difference.An additional consideration in the assessment of TAVR cost-effectiveness is the impact of access site.Although TAVR via nontransfemoral (TF) access may be preferred to SAVR in some circumstances, available data from randomized trials have failed to demonstrate any clear advantage of non-TF TAVR over SAVR in either highor intermediate-risk patients.Furthermore, the reductions in LOS with non-TF TAVR relative to SAVR have been small.The net result is that the cost-effectiveness of TAVR relative to SAVR has been generally favorable for patients eligible for TF access, but less so for patients only suitable for non-TF approaches.