NEW ORLEANS – The cost of transcatheter aortic valve replacement among patients with inoperable severe aortic stenosis is in line with the cost of other accepted cardiovascular procedures, according to an economic analysis of the PARTNER trial.
The index hospitalization costs were higher with TAVR, but the reduction in subsequent hospitalizations, and the projected gain in survival, associated with the procedure yielded overall lifetime cost-effectiveness. “In this extremely high-risk population, an elderly population, the intervention is adding roughly 2 years of life, and that is the return on investment,” principal investigator Dr. Matthew Reynolds said at the meeting. The cost-effectiveness ratio “works out to just over $50,000 per life-year gained.”
Efficacy data for the same 358 inoperable patients, known as cohort B, showed a 20% survival benefit with TAVR at 1 year, compared with standard medical therapy, including balloon aortic valvuloplasty (N. Engl. J. Med. 2010; 363:1597-1607).
To determine the economic value of the procedure, Dr. Reynolds and his colleagues assessed lifetime incremental cost-effectiveness ratios (ICERs) and lifetime incremental costs per QALY using hospital billing data or MEDPAR when bills were unavailable. Costs from the last 6 months for surviving patients were used to project future costs beyond 12 months, while parametric survival models fit to the trial data were used to extrapolate patient-level life expectancy beyond the follow-up period.
The initial $78,540 price tag for TAVR includes $42,806 for procedural costs, based on an estimated cost of $30,000 for the investigational Edwards Sapien valve; $30,756 for nonprocedural expenses; and $4,978 for physician fees, said Dr. Reynolds, director of the Economics and Quality of Life Research Center at the Harvard Clinical Research Institute, Boston. Twelve-month follow-up costs were $23,372 higher for patients treated with standard medical therapy. This was a result of significantly more hospitalizations in the control group than in the TAVR group (2.15 vs. 1.02), mainly due to cardiovascular causes (1.7 vs. 0.50).
The estimated life expectancy was 3.1 years for TAVR patients and 1.2 years fortpatients treated with medical therapy, or a difference of 1.9 years. The lifetime incremental cost per patient was $79,837, and the lifetime incremental gain in life expectancy was 1.59 years. This translated into an ICER of $50,212 per life-year gained and $61,889 per QALY, he said.
On the basis of the data, TAVR in this older inoperable cohort falls very close to published cost-effectiveness estimates for implantable defibrillators and atrial fibrillation ablation, and is actually lower than current estimates for hemodialysis or percutaneous coronary intervention for stable coronary artery disease, Dr. Reynolds said.
Edwards Lifesciences provided grant support for the analysis.