TAVR 2018: Cost-effective according to baseline patient risk. A real-world case example

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Lynne Gordon
5 years ago
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1 TAVR 2018: Cost-effective according to baseline patient risk A real-world case example

2 Male, 74 years old HTN, dyslipidaemia, CAD, PAD Past Hx 1991: CABG (LIMA LAD, SVG RCA) 2014: carotid endarterectomy Other Medical Hx Laryngeal cancer successfully treated with excision and radiotherapy

3 Dyspnoea on mild exertion (NYHA III-IV) Clinical examination: BP: 135/85 mmhg, HR: 76bpm Normal peripheral pulses JVP not elevated S1 & S2 normal; 4/6 systolic murmur at the right parasternal area radiating to the carotids Lungs clear no hepatomegaly; no peripheral oedema

4 Meds - ASA 100 mg od, - metoprolol 100 mg 1/4 bid - furosemide 40 mg od - atorvastatin 10 mg od - omeprazole 20 mg od - allopurinol 100mg od - magnesium supplements

17 Cost-effectiveness analysis: is a form of economic analysis that compares the relative costs and outcomes (effects) of different courses of action. How to evaluate the Cost- Effectiveness? TAVI AVR Medical Therapy Intermediate/low risk patients High-risk patients Inoperable patients Cost 1. Costs 2. Quality Adjusted life Year (QALY), 3. Life Year Gained (LYG) 4. Incremental cost effectiveness ratio (ICER) Effectiveness 1. Mortality and Adverse event rates 2. Quality of Life

18 TAVI TAVI versus AVR Cost AVR DRG (K56X): 8 days euro (K56M): 12 days euro TAVI procedure: euro DRG (K04X): 8 days (K04M): 14 days Valve procedure: Valve: euro Pacemaker no Follow-up period: DAPT for 3 months and then only aspirin Rest medical therapy for CAD ~ euro Valve: 1. Mechanical: 2000 euro, 2. Biological: 2750 euro, 3. Sutureless: 6900 euro Pacemaker no Follow-up period: Depending on valve selection Rest medical therapy for CAD Rehabilitation program ~ euro + Rehabilitation ~ euro Sutureless

Mortality and Adverse event rates TAVI: PVL, PCM Expected at least 10 years w/o valve related complications AVR: Increased mortality, Periprocedural AF, Bleeding, AKI,

19 Mortality and Adverse event rates TAVI: PVL, PCM Expected at least 10 years w/o valve related complications AVR: Increased mortality, Periprocedural AF, Bleeding, AKI, Recovery time Quality of Life: TAVI: Improvement AVR: The number of QALYs gained by TAVI compared with AVR in high-risk surgical candidates ranged from to Improvement

20 TAVI TAVI versus Medical Cost Medical DRG (K56X): 8 days euro (K56M): 12 days euro TAVI procedure: Valve: euro Pacemaker no Follow-up period: euro Optimization of medical therapy Multiple hospitalizations Additional therapy may be needed (ICD or CRT-D) Social security program for in-house hospitalization DAPT for 3 months and then only aspirin Rest medical therapy for CAD ~ euro Over the projected lifetime of these patients TAVR was economically attractive with an ICER of USD$61,889/QALY gained (PARTNER Cohort B)

21 Mortality and Adverse event rates TAVI: PVL, PCM Expected at least 10 years w/o valve related complications Medical: Increased mortality rate, HF, Re-hospitalization Quality of Life: TAVI: TAVΙ was associated with a 20% absolute reduction in 1- year mortality, which was sustained after 5 years of followup (PARTNER B Cohort) Improvement Medical: TAVI was shown to improve the quality of life by 0.60 to 1.56 QALY (PARTNER A and B cohort) Further deterioration

22 Address major issues for cost-effectiveness: Stroke Paravalvular leakage Pacemaker implantation Cost Cost Durability Thrombosis

23 EFFECTIVENESS Better clinical outcomes Less Pain Faster recovery COST Reduce Hospital stay Reduce complications

Rarely does a new medical technology offer clinical superiority at a lower cost TAVR seems to provide meaningful clinical benefits compared with SAVR Procedural costs are

24 Rarely does a new medical technology offer clinical superiority at a lower cost TAVR seems to provide meaningful clinical benefits compared with SAVR Procedural costs are substantially higher with TAVI than with SAVR, and these costs may be offset by savings from shortened hospital length of stay and by reduced need for post-discharge residential care

25 The cost-effectiveness of TAVI compared with medical therapy would likely be greater for patients deemed inoperable for anatomic reasons, such as a porcelain aorta, chest wall deformity, or previous thoracic radiotherapy. These patients will be more likely to experience favorable outcomes after TAVI procedures because of having fewer medical comorbidities. Overall, despite the much greater initial costs, the improvement in the quality and longevity of life suggests that TAVI might be an efficacious and cost-effective alternative to medical therapy for symptomatic inoperable patients. Indraratna et al, J Thorac Cardiovasc Surg 2014;148:509-14

Surgical AVR: Are there any contraindications? Pyowon Park Samsung Medical Center Seoul, Korea

Surgical AVR: Are there any contraindications? Pyowon Park Samsung Medical Center Seoul, Korea Contents Decision making in surgical AVR in old age Clinical results of AVR with tissue valve Impact of 19mm