Lower Costs for TAVI Valves Could Improve Access, Analysis Hints

High costs associated with TAVI have led to decreased access at institutions that cannot afford to offer it, leading to socioeconomic, geographic, and racial inequities across the United States, according to a new review paper.

Ultimately, lowering the cost of the TAVI valves themselves—likely through competition as new prostheses come to market—is what will even the playing field, the authors predict.

“There are significant economic considerations surrounding TAVR in the United States, and we as a community have to think very carefully about what we can do to make sure that access is available to all patients,” senior author Ashwin Nathan, MD (Hospital of the University of Pennsylvania, Philadelphia), told TCTMD. “That's been the priority of the work I've done to make sure that this very exciting and lifesaving technology is available to all subsets of the population.”

The review, with Kriyana P. Reddy, BS (University of Pennsylvania), as lead author, was published online this month in Circulation: Cardiovascular Interventions.

In doing a deep dive of the literature, Nathan said the team’s goal was to summarize what the most important current economic considerations should be for clinicians and administrators when thinking about TAVI. PARTNER 3 data released at TCT 2021 showed that costs over 2 years are about $2,000 cheaper for TAVI versus surgical AVR, with valve price driving the initial difference.

The variation in TAVI across geographic regions as well as within different ethnic and racial populations is “something that we were trying to highlight,” Nathan said. “What we learned is that the contribution margins for TAVR can be extremely low—part of it is due to the cost of the valve, as well as reimbursement from CMS for the TAVR procedure. As a result, it can be financially difficult for some programs to maintain TAVR programs.”

Thanks to having been around longer, surgical valves are cheaper than the ones used for TAVI and there are more options to choose from. This means that at certain institutions, Nathan continued, “it may financially make more sense to pursue surgical AVR, even though obviously the data for TAVR is very good in low-, intermediate-, and high-risk patients.”

Does this mean that TAVI should be restricted to institutions that can afford it? Not necessarily, Nathan said. While the economics may drive how many procedures a program can annually sustain, the focus should remain on increasing access, especially for underserved populations. “It may be that the high cost of the valve and the low reimbursements preclude some programs that serve predominantly poor patients—and are already operating on thin margins—from being able to offer this novel, exciting, lifesaving technology to their patients,” he said.

To improve access across the board, Nathan said he would like to see policy changes that either lower TAVI valve costs or increase competition, which will naturally make the devices more affordable as was seen with coronary stents. “The other thing that could change would be increasing the reimbursement for it so that hospitals can afford to offer this procedure,” he said, adding that the proliferation of so-called minimalist TAVI with conscious sedation and shorter lengths of stay will help decrease costs.