Proving the cost-effectiveness of TAVR

When it comes to TAVR, what is good for patients is good for economics too. Or more specifically, what is good for Medicare patients with severe aortic stenosis at intermediate risk for surgery is good for reductions in U.S healthcare costs. The amount depends on where you live, with CMS reimbursing much higher on the East and West Coasts versus the center of the country with valve costs remaining the same.

As you likely heard last week from the Transcatheter Cardiovascular Therapeutics (TCT) scientific symposium in Denver, despite initial higher costs, TAVR offset savings long term via shorter initial hospital stays as well as fewer readmissions and nursing home days in the first six months after the procedure compared with surgical AVR (SAVR), according to Analysis of the PARTNER 2A trial and the SAPIEN-3 Intermediate Risk registry.

The research team linked patients with Medicare claims data to calculate costs associated with index hospitalizations, follow-up hospitalizations, physician services, outpatient testing and custodial care.

Although procedural costs remain substantially higher with TAVR versus SAVR, TAVR with the Sapien XT or Sapien 3 valve (Edwards Lifesciences) provided greater quality-adjusted life expectancy and lower costs over time for intermediate-risk patients than SAVR, according to data presented by David J. Cohen, MD, MSc, of Saint Luke's Mid America Heart Institute, Kansas City, Mo., and supported by Edwards.

Last year, the FDA expanded the indications for the Sapien XT and Sapien 3 valves for use in intermediate-risk patients. While prior studies have shown TAVR is cost effective, little had been known about the economics of using these devices compared with surgery. TAVR is an “economically dominant strategy,” Cohen said.

But will this change clinical practice? Probably not because this is the way we are already headed. From 2012 to 2015, we saw a 323 percent increase in procedures, according to The Advisory Board Company, and numbers have climbed since. And as Cohen noted: “Practice is driven right now by the clinical data, which are already good, and by the patient demand, which is high.”

And surgeons, who some think would be negatively affected by the results, are already involved due to the Medicare mandate that all TAVR patients be reviewed with a heart team approach. So they’re not putting up a fight, according to Cohen.

When it comes to the economics, “remarkable” is how panelist Duane Pinto, MD, MPH, of Beth Israel Deaconess Medical Center in Boston, described the findings at the TCT press conference. But it is the U.S. healthcare system that will see the benefits versus individual hospitals. “It really depends on the reimbursement for TAVR,” he said. “We may be saving society money, but we may not necessarily be ‘making money’ for the hospital in that regard.”

Cohen acknowledged Pinto’s comments and predicted the lower rate of 90-day complications seen with TAVR could benefit hospitals that have reimbursement incentives for reducing rehospitalizations. “Even to the hospitals if they are in a bundled payment [model] or an HMO type environment, they'll do well,” he said.

While TAVR is increasingly used in intermediate-risk patients, research is just beginning on the procedure in low-risk patients with aortic stenosis, who are typically indicated for SAVR. “I don’t know what the clinical nor the economic issues will be once we start seeing data from that population,” Cohen said. “I think [TAVR] growth will be relatively modest for the next few years until that low-risk population has some decent data.”

And as we know, we can’t think of TAVR as just a procedure, it is part of a structural heart program uniting many disciplines and services across the hospital to ensure appropriate treatment and care plan decisions. The sum is greater than its parts. To physicians, it means multidisciplinary decision-making and care coordination. To hospital administrators watching the fiscal health of the program, it means improvements in throughput and the ability to fill more beds with paying patients. Together, the team approach is a success, improving the care of patients and the health and sustainability of care.