BACKGROUND: The recent Placement of AoRTic TraNcathER Valves (PARTNER) 3 trial showed that balloon-expandable transcatheter aortic valve replacement (TAVR) was superior to surgical aortic valve replacement (SAVR) at 30 days for the outcome of death or stroke and at one year for the composite outcome of mortality, stroke, and readmission. However, the cost of TAVR valves remain significantly higher than surgical valves, whilst the procedural times and hospital length of stays were shorter with TAVR in the PARTNER 3 trial; thus the cost-effectiveness of TAVR versus SAVR remains unknown. Our objective was to determine the cost-effectiveness of TAVR in the low surgical risk population.
METHODS AND RESULTS: A cost-utility analysis from the Canadian healthcare system payer’s perspective was undertaken comparing transfemoral balloon-expandable TAVR to SAVR in low surgical risk patients (STS predicted mortality < 4%). A fully probabilistic Markov cohort model was constructed to estimate differences in costs (2019 Canadian dollars) and effectiveness (as quality-adjusted life years [QALYs]) over a life-time time horizon, discounted at 1.5%/annum with 30-day cycle lengths. We included the following health states: alive/well, permanent stroke, paravalvular leak ≥mild, re-hospitalization, and death. Efficacy inputs were from PARTNER 3, cost inputs from the Canadian Institute for Health Information Patient Cost Estimator and St. Michael's Hospital, and utilities were obtained from the published literature (Table). Incremental-cost effectiveness ratios (ICER) were calculated. One-way deterministic sensitivity analyses (DSA) were conducted around cost and efficacy point estimates to address uncertainty. In the base-case analysis, with discounting, the total lifetime costs in the TAVR and SAVR arms were $34,978±4562 and $28,772±6754 respectively while total effectiveness were 9.40±3.22 and 9.27±3.18 QALYs respectively, yielding an ICER of $46,338/QALY. At willingness-to-pay (WTP) thresholds of $50,000, $100,000, $150,000 respectively, 44.0%, 56.2%, and 61.6% of 100,000 model simulations were below the thresholds respectively (Figure). One-way DSA demonstrated that the ICER was impacted by the cost of the TAVR valve, surgical valve, peri-operative death and stroke rates in the surgical arm.
CONCLUSION: Balloon-expandable TAVR was found to be likely cost-effective from the Canadian healthcare system at a WTP threshold of $100,000/QALY. Additional long-term durability follow-up data will be necessary to better understand the cost-effectiveness of TAVR versus SAVR in low risk patients.