Is transcatheter aortic valve implantation (TAVI) a cost-effective treatment in patients who are ineligible for surgical aortic valve replacement? A systematic review of economic evaluations

Abstract

Objectives:

Health Technology Assessment (HTA) agencies often undertake a review of economic evaluations of an intervention during an appraisal in order to identify published estimates of cost-effectiveness, to elicit comparisons with the results of their own model, and to support local reimbursement decision-making. The aim of this research is to determine whether Transcatheter Aortic Valve Implantation (TAVI) compared to medical management (MM) is cost-effective in patients ineligible for surgical aortic valve replacement (SAVR), across different jurisdictions and country-specific evaluations.

Methods:

A systematic review of the literature from 2007–2012 was performed in the MEDLINE, MEDLINE in-process, EMBASE, and UK NHS EED databases according to standard methods, supplemented by a search of published HTA models. All identified publications were reviewed independently by two health economists. The British Medical Journal (BMJ) 35-point checklist for economic evaluations was used to assess study reporting. To compare results, incremental cost effectiveness ratios (ICERs) were converted to 2012 dollars using purchasing power parity (PPP) techniques.

Results:

Six studies were identified representing five reimbursement jurisdictions (England/Wales, Scotland, the US, Canada, and Belgium) and different modeling techniques. The identified economic evaluations represent different willingness-to-pay thresholds, discount rates, medical costs, and healthcare systems. In addition, the model structures, time horizons, and cycle lengths varied. When adjusting for differences in currencies, the ICERs ranged from $27K–$65K per QALY gained.

Conclusions:

Despite notable differences in modeling approach, under the thresholds defined by using either the local threshold value or that recommended by the World Health Organization (WHO) threshold value, each study showed that TAVI was likely to be a cost-effective intervention for patients ineligible for SAVR.

Keywords::

• Aortic stenosis
• Aortic valve disease
• Cost benefit analysis
• Percutaneous valve therapy
• Systematic review
• TAVI

Transparency

Declaration of funding

The study was sponsored by a consultancy agreement between Medtronic International Sàrl Limited and Oxford Outcomes an ICON Plc Company. No restrictions were placed by Medtronic International Sàrl Limited on the design of the study, the choice of included articles or the presentation of results. Publication of the manuscript was not contingent on sponsor approval or censorship of the contents.

Declaration of financial/other relationships

James Eaton, Stuart Mealing, and Juliette Thompson are employees of Oxford Outcomes, an international consultancy firm, and have undertaken similar analyses for a number of healthcare firms. Rachele Busca is an employee of Medtronic International Sàrl Ltd., Neil Moat and Nicolo Piazza have provided consultancy services to Medtronic International Sàrl Ltd. Pieter Kappetein and Ruben Osnabrugge had no competing interest. JME peer reviewers on this manuscript have no relevant financial relationships to disclose.

Author contributions: All authors are justifiably credited with authorship, according to the authorship criteria. In detail: JE, SM, and JT—conception, design, analysis, and interpretation of data, drafting of the manuscript, final approval given; RB—conception, design, final approval given; NM and NP—analysis and interpretation of data, final approval given; APK—critical revision of manuscript, final approval given; RLJO—interpretation of data, drafting of the manuscript, final approval given.