Reardon MJ, Geisler BP, Popma JJ, van Mieghem NM, Serruys P, Deeb GM, Windecker S, Yakubov SJ, Søndergaard L, Pietzsch JB. Cost-effectiveness of transcatheter aortic valve implantation in patients at intermediate surgical risk: a model-based analysis based on the SURTAVI trial using contemporary cost data [abstract Euro19A-POS532, online]. Poster presentation at EuroPCR 2019, Paris, May 20-24, 2019. Available at: https://abstractbook.pcronline.com/export/pdf/id/130675.

Objectives. Clinical non-inferiority between transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR) has previously been demonstrated for patients with severe aortic stenosis at intermediate surgical risk. While the cost-effectiveness of TAVI has been studied in other populations–typically extreme-risk or high-risk cohorts—additional data about the health economics of TAVI for intermediate-risk patients are desirable.

Methods. Mortality, clinical event rates, and rehabilitation resource utilization were derived from the SURTAVI trial (864 TAVI and 796 SAVR patients, with a Society of Thoracic Surgeons predicted risk of mortality score of 4.5% ±1.6%). The patients’ mean age was 79.8 ±6.2 years. Cost data for the index procedure and adverse events were based on an analysis of real-world data for TAVI and SAVR procedures from the US Medicare population in 2017 (Medpar inpatient dataset, including 38,120 TAVI patients and 40,046 SAVR patients), with reported charges adjusted to cost using site-specific cost-to-charge ratios. Rehabilitation and long-term follow-up costs were derived from Medicare fee schedules as a proxy for true cost and data from the published literature. All costs were inflated to 2018 costs using the medical consumer price index.

Costs and effectiveness were expressed in quality-adjusted life years (QALYs) and projected to a lifetime horizon via a decision-analytic (Markov) model calibrated to 24-month incidents of all-cause mortality and stroke from the SURTAVI trial. Several scenarios were considered where–after either 24-month data or an assumed catch-up of mortality at 48 months—relative mortality risks were maintained, or would gradually fade out over time. The discounted incremental cost-effectiveness ratio (ICER) was compared to a willingness-to-pay threshold of $150,000 per QALY gained, as outlined in guidelines from the American Heart Association and American College of Cardiology.

Results. Index hospitalization costs were slightly lower for TAVI than for SAVR ($57,782 vs. $59,899; for a difference of –$2,118). When considering rehabilitation (mean of 1.30 and 4.30 days for TAVI and SAVR, respectively), TAVI resulted in lower costs at the 30-day follow-up ($59,794 vs. $66,287; for a difference of –$6,493). Lower TAVI costs were maintained through a lifetime horizon. Depending on the long-term mortality scenario used, TAVI either gained or lost a small number of QALYs when compared to SAVR.

Conclusions. Among intermediate-risk patients, TAVI was found to be associated with lower cost when compared to SAVR, based on contemporary cost and resource utilization data from the United States. Follow-up analyses considering longer term survival data would be desirable to further corroborate long-term cost-effectiveness.