PARTNER: TAVR Cost-Effectiveness Evaluated in Inoperable Patients

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Use of transcatheter aortic valve replacement (TAVR) in inoperable patients with severe aortic stenosis not only improves survival and quality of life but does so within acceptable bounds of cost-effectiveness, according to a study published online February 3, 2012, ahead of print in Circulation.

The findings were originally presented in April 2011 at the annual American College of Cardiology Scientific Session/i2 Summit in New Orleans.

David J. Cohen, MD, of the Mid America Heart and Vascular Institute (Kansas City, MO), and colleagues examined the cost-effectiveness of TAVR based on data from Cohort B of the PARTNER (Placement of AoRtic TraNscathetER valve) trial, which randomized 358 inoperable patients with severe aortic stenosis to standard therapy (n = 179) or TAVR (n = 179; all via the transfemoral route) with the Edwards Sapien valve (Edwards Lifesciences, Irvine, CA). TAVR reduced all-cause mortality and repeat hospitalizations.

For the current analysis, the investigators evaluated data on survival, quality of life, medical resource use, and hospital costs, including follow-up costs.

The total mean cost of the TAVR procedure and associated hospital stay was $78,542, including:

• $31,631 for the valve system
• $30,757 for the hospital room and ancillary costs (mean length of stay 10.1 days)
• $4,979 for physician fees    

Despite Fewer Hospitalizations, TAVR Costs Remain High

During the 12-month follow-up period, patients who underwent TAVR had a mean 1.0 hospital visits at a cost of $18,074 vs. 2.2 visits for the control group at a cost of $44,099, resulting in a saving of $26,025 in favor of TAVR (P < 0.001). Although TAVR patients spent more time in rehabilitation and skilled nursing facilities during this period, the added cost (about $2,500) was not significant. Overall, however, the cumulative 1-year cost for TAVR was twice that for standard therapy: $106,076 vs. $53,621 (P < 0.01).

Based on survival models, TAVR patients were projected to have a quality-adjusted life expectancy 1.6 years longer than their counterparts who received standard therapy at an incremental cost of $79,837. This resulted in an estimated cost of $50,200 per year of life gained or $61,889 per quality-adjusted life-year gained.

Overall a Good Value

In an interview with TCTMD, Ajay J. Kirtane, MD, SM, of Columbia University Medical Center (New York, NY), said it should be recognized that the increase in survival associated with TAVR will most likely lead to increased cumulative health care costs.

“There are hospital costs beyond the initial valve implantation,” Dr. Kirtane said. “These patients, even though they get the valve, may come back to the hospital [for a variety of other reasons over time] and you may expose them to other illnesses that they otherwise may not have gotten.”

However, the increase in cumulative costs does not detract from the appeal of the procedure in the inoperable patient population, he insisted.

“Some people may say it is on the borderline between clearly cost effective and in a gray zone, but I think it is very reasonable in the context of other things we pay for,” Dr. Cohen told TCTMD in a telephone interview. “It is quite similar to cost effectiveness of things like implantable defibrillators for patients with class II or III heart failure or the new antithrombin drugs for patients with atrial fibrillation.”

In an accompanying editorial, Mark A. Hlatky, MD, of Stanford University (Stanford, CA) and C. Torrey Simons, MD, PhD, of the Veterans Affairs Palo Alto Healthcare System (Palo Alto, CA), agreed with Dr. Cohen. Given that the study data met the 2 vital criteria of cost effectiveness—improvements in survival and quality of life compared with the next best treatment—“TAVR may be a good value in properly selected symptomatic patients with aortic stenosis who are at too high a risk to have surgical AVR,” they write.

Data Apply Only to Inoperable Patients

Drs. Hlatky and Simons caution, however, that the findings on TAVR cost-effectiveness are not generalizable to other patient populations.

“It is important to understand that if you treat patients that are even sicker than those in this trial, they may not live as long,” Dr. Cohen said. “How long patients live after TAVR is a very important factor in its cost effectiveness.”

Nonetheless, Dr. Kirtane concluded, “Given the fact that this procedure not only was live-saving but occurred at not that much a greater expense [than standard therapy] means that this technology should be here to stay and will be a core cardiovascular procedure in the future.”

 

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Sources:
1. Reynolds MR, Magnuson EA, Wang K, et al. Cost effectiveness of transcatheter aortic valve replacement compared with standard care among inoperable patients with severe aortic stenosis: Results from the PARTNER trial (cohort B). Circulation. 2012;Epub ahead of print.

2. Hlatky MA, Simons CT. Cost-effectiveness of transcatheter aortic valve replacement. Circulation. 2012;Epub ahead of print.

 

 

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