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Economic data behind TAVI – uncovering the cost-saving factors

Economic data behind TAVI

Cost savings in transcatheter aortic valve implantation (TAVI) cohorts, compared to surgical aortic valve replacement (SAVR), are driven mainly by shorter length of stay, as well as fewer complications and required resources.1–3 Such findings support prioritisation of TAVI over SAVR in patients with severe AS for whom TAVI is suitable across low-, intermediate- and high- surgical risk.2,4 Minimalist TAVI (M-TAVI) should also be considered to take the cost saving further, without compromising efficacy or safety.5

Policy makers may consider such benefits to inform a holistic consideration including both medical and societal impact, instead of considering procedural, rehabilitation, and budget separately.1

Higher costs of the TAVI valve are offset by lower short- and long-term costs

TAVI was introduced as an alternative to SAVR for the treatment of severe symptomatic aortic stenosis (AS). Initially only considered for patients with inoperable disease or those at high risk of surgical mortality, TAVI is now an effective and safe option for patients at intermediate or low risk of surgical death.1–3

The benefits of TAVI stem further than solely clinical efficacy, with research in recent years showing the proven cost effectiveness, compared with SAVR. Initially, concerns arose of the higher procedural costs of TAVI, yet this is not consistently reported: while procedural costs of TAVI were reported at €3,317 higher per patient over a lifetime horizon than for SAVR in Italy, a recent study based in France confirmed lifetime intervention costs per person (without pacemaker) to be €8,139 compared to a higher €22,603 for SAVR.1–3

The low short- and long-term costs of TAVI confirm its cost effectiveness

Upon closer inspection, the reported higher valve costs of TAVI were offset by the lower short-term non-procedural costs, such as rate of complications, time spent in intensive care unit (ICU) and overall length of hospitalisation.1,3 A US cost-effectiveness study based on data from the PARTNER 3 trial showed that despite the overall hospital index costs for TAVI being marginally higher, the non-procedural costs were $7,174 compared to $23,578 for SAVR; non-procedural costs included procedure duration, length of stay and discharge disposition.6 Consequently total 2-year costs for TAVI were $2,030 less than for SAVR.6

Lower rate of complications

TAVI with the SAPIEN 3 valve shows a compelling value-based case for patients in France driven by lower long-term management costs of disabling stroke and treated atrial fibrillation (AF).2 Lifetime costs relating to disabling stroke and treated AF were €5,744 and €5,219 less than for SAVR, respectively.2  
 
In Norway, TAVI with the SAPIEN 3 valve is seen to be dominant over surgery in the low-risk population, as it is more effective (gain of 0.05 quality adjusted life years (QALY)) and less costly (saving of NOK 35,000) over a 15-year horizon.7 This is consistent with findings from Italy, where lower complication rates drive cost-effectiveness of TAVI with the SAPIEN 3 valve. This lower rate of complications means that TAVI is cost-effective at a willingness-to-pay threshold of €30,000/QALY.1

Shorter length of hospital stays

In a US-based study, significantly lower rates of major bleeding contribute to the cost effectiveness of TAVI using SAPIEN 3 valve over SAVR in intermediate-risk patients.3 In this study, however, the lower overall non-procedural costs of TAVI are primarily driven by the total length of hospital stay, which was on average 6.3 days shorter.3 This was comprised of a 2.8-day shorter ICU stay, 3.5-day shorter non-ICU stay and 5.6 days shorter post-procedure stay, and thus a €23,035 cost saving.3

Findings from a Spanish public hospital also confirmed the shorter hospital stay following TAVI. This clinical benefit reflected a considerable reduction in cost from €8,263.10 per patient for SAVR to €3,709.90 per patient for TAVI.8

Fewer resources required

Staff costs are considerably lower following percutaneous TAVI compared to SAVR.8 In Spain, the staff allocated to TAVI were required for only 158 minutes per procedure, compared to 261 minutes for SAVR which incurred a cost saving of €537.50 per patient (€308.10 TAVI vs. €845.60 SAVR).8 This was also seen in the PARTNER 3 trial where procedure time for TAVI was 59 minutes compared to 208 minutes, thereby contributing to the overall cost-saving6.

TAVI using the SAPIEN 3 valve was also associated with a >50% reduction in total rehabilitation/skilled nursing days (versus SAVR) and a cost-saving of $5,169 in low-risk patients in the US.3 In an Italian cohort of intermediate patients, rehabilitation costs following TAVI using SAPIEN 3 valve were €1,594 less than SAVR.1

Optimising cost-saving benefits of TAVI

Despite considerable cost saving benefits of TAVI compared to SAVR, there are ways to optimise this further. One way is the use of M-TAVI, which entails moderate sedation, percutaneous vascular access, and post-implant transthoracic echocardiography (TTE); M-TAVI has similar rates of complications to conventional TAVI, as well as lower all-cause mortality.5,9

Compared to conventional TAVI, length of stay associated with M-TAVI was 28% shorter and patients were more likely to be discharged home.9 The overall length of hospital stay for multidisciplinary, modality, minimalist (3M) TAVI more than half that of conventional TAVI using the SAPIEN 3 valve (1.6 vs. 3.9 days) incurring an in-hospital cost-saving of $4,377.10 In a UK-based study, mean ICU length of stay was 5.1 hours for M-TAVI and 57.2 hours for conventional TAVI, incurring a saving of £1,638.5

The shorter total procedure time of 115 minutes, compared to 181 minutes for conventional TAVI using the SAPIEN 3 valve incurred a cost saving of $1,551.10 Drug costs were also £213 less in the M-TAVI group, giving an overall cost saving of £3,580 despite the initial valve costs being considerably higher.5

References

  1.        Mennini FS, Meucci F, Pesarini G, et al. Cost-effectiveness of transcatheter aortic valve implantation versus surgical aortic valve replacement in low surgical risk aortic stenosis patients. Int J Cardiol. 2022;357:26-32. doi:10.1016/j.ijcard.2022.03.034
  2.        Gilard M, Eltchaninoff H, Iung B, et al. Cost-Effectiveness Analysis of SAPIEN 3 Transcatheter Aortic Valve Implantation Procedure Compared With Surgery in Patients With Severe Aortic Stenosis at Low Risk of Surgical Mortality in France. Value Health. 2022;25(4):605-613. doi:10.1016/j.jval.2021.10.003
  3.        Baron SJ, Wang K, House JA, et al. Cost-Effectiveness of Transcatheter Versus Surgical Aortic Valve Replacement in Patients With Severe Aortic Stenosis at Intermediate Risk. Circulation. 2019;139(7):877-888. doi:10.1161/CIRCULATIONAHA.118.035236
  4.        Baron SJ, Ryan MP, Moore KA, Clancy SJ, Gunnarsson CL. Contemporary Costs Associated With Transcatheter Versus Surgical Aortic Valve Replacement in Medicare Beneficiaries. Circ Cardiovasc Interv. 2022;15(3):e011295. doi:10.1161/CIRCINTERVENTIONS.121.011295
  5.        Sangaraju S, Cox I, Dalrymple-Hay M, et al. Effect of procedural refinement of transfemoral transcatheter aortic valve implantation on outcomes and costs: a single-centre retrospective study. Open Heart. 6(2):e001064. doi:10.1136/openhrt-2019-001064
  6.        Cohen D. Economic Outcomes of TAVR vs. SAVR for Low-Risk Patients: Results from the PARTNER 3 Trial. Presentation TCT 2021.
  7.        Himmels JP, Flottorp S, Stoinska-Schneider A, Fagerlund Kvist BC, Robberstad B. Transcatheter aortic valve implantation (TAVI) versus surgical aortic valve replacement (SAVR) for patients with severe aortic stenosis and  low surgical risk and across surgical risk groups: a health technology assessment. Report 2021.  . Oslo: Norwegian Institute of Public Health. Published online 2021.
  8.        Areces S, Hernández-Vaquero D, Avanzas P, García-Aranda FJ, Silva J, Morís C. Cost comparison between transcatheter aortic valve implantation and surgical valve replacement using individual data in a Spanish public hospital. Cirugía Cardiovascular. 2021;28(6):317-324. doi:10.1016/j.circv.2021.07.006
  9.        Harjai KJ, Bules T, Berger A, et al. Efficiency, Safety, and Quality of Life After Transcatheter Aortic Valve Implantation Performed With Moderate Sedation Versus General Anesthesia. Am J Cardiol. 2020;125(7):1088-1095. doi:10.1016/j.amjcard.2020.01.002
  10.      Buttala N (On behalf of the 3M TI. Economics of minimalist TAVR: The 3M TAVR economic study. Presentation TVT 2021.

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