Cost-Effectiveness of TAVR vs. SAVR
What is the cost-effectiveness of transcatheter aortic valve replacement (TAVR) with a self-expanding prosthesis compared to surgical aortic valve replacement (SAVR)?
A formal economic analysis was performed on the basis of individual patient-level data from the CoreValve U.S. High Risk Pivotal Trial. Empirical data regarding survival and quality of life over 2 years, and medical resource use and hospital costs through 12 months were used to project life expectancy, quality-adjusted life expectancy, and lifetime medical costs in order to estimate the incremental cost-effectiveness of TAVR compared to SAVR in the United States.
Relative to SAVR, TAVR reduced initial length of stay an average of 4.4 days, decreased the need for rehabilitation services at discharge, and resulted in superior 1-month quality of life. Index admission and projected lifetime costs were higher with TAVR than with SAVR (differences $11,260 and $17,849 per patient, respectively), whereas TAVR was projected to provide a lifetime gain of 0.32 quality-adjusted life-years (0.41 life-years with 3% discounting). Lifetime incremental cost-effectiveness ratios were $55,090 per quality-adjusted life-year gained and $43,114 per life-year gained. Sensitivity analysis indicated that a reduction in the initial cost of TAVR by approximately $1,650 would lead to an incremental cost-effectiveness ratio of <$50,000 per quality-adjusted life-year gained.
In a high-risk clinical trial population, TAVR with a self-expanding prosthesis provided meaningful clinical benefits compared with SAVR, with incremental costs considered acceptable by current US standards. With expected modest reductions in the cost of index TAVR admissions, the value of TAVR compared with SAVR in this patient population would become higher.
Based on this analysis, TAVR with a self-expanding prosthesis in the United States resulted in higher (but not prohibitive) index admission and lifetime costs compared with SAVR, with a small associated gain in quality-adjusted life-years. Although TAVR should not be seen as having a cost advantage over SAVR, it falls within current thresholds for an acceptable expense. With unknown long-term durability of currently available TAVR devices, extrapolation of these findings to lower-risk and to younger patient populations probably is not appropriate.
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