TCT 2017: TAVR ‘economically dominant’ over SAVR for aortic stenosis patients at intermediate risk

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DENVER — Transcatheter aortic valve replacement (TAVR) is an “economically dominant” strategy compared to surgical aortic valve replacement (SAVR) for patients with aortic stenosis at intermediate surgical risk, according to data presented by David J. Cohen, MD, MSc, Oct. 31 at the Transcatheter Cardiovascular Therapeutics (TCT) scientific symposium.

Although the TAVR procedures themselves were more expensive due to higher valve cost, those costs were offset—and eventually overcome—by savings from shorter initial hospital stays and fewer readmissions and nursing home days within the first six months following the procedure.

Cohen presented data from the PARTNER 2A randomized trial as well as the SAPIEN 3 registry containing TAVR patients at intermediate risk. He and colleagues linked patients with Medicare claims data to calculate costs associated with index hospitalizations as well as follow-up hospitalizations, physician services, outpatient testing and custodial care.

TAVR showed projected lifetime cost savings of $7,949 per patient in PARTNER 2A and $9,692 in SAPIEN 3. In addition, it was associated with greater quality adjusted life expectancy in both analyses—0.15 years for PARTNER and 0.27 years for SAPIEN 3.

“For patients with severe aortic stenosis and intermediate surgical risk, similar to those enrolled in the PARTNER 2 trial, TAVR using either the SAPIEN XT or the SAPIEN 3 valve is an economically dominant strategy compared to surgical AVR, providing both greater quality adjusted life expectancy and lower long-term costs than surgery with a high degree of confidence,” said Cohen, who received research grant support from Edwards Lifesciences, the maker of the SAPIEN valves. “Taken together with the clinical data we know, these findings suggest TAVR should be the preferred strategy for such patients based on both clinical and economic considerations.”

The PARTNER trial contained 944 patients randomized to either TAVR or SAVR. Procedural costs were $22,083 higher with TAVR than SAVR but hospital stays were 4.5 days shorter, making the index hospital costs a marginal $2,900 higher for TAVR patients. Hospital stays were even shorter for SAPIEN 3 patients when compared to the PARTNER SAVR cohort (4.6 versus 10.9 days), resulting in lower total costs for index hospitalizations with TAVR.

Both TAVR groups experienced fewer follow-up complications and related costs versus SAVR, particularly in the first six months, Cohen said.

“There were substantial reductions of readmissions and there was about halving of the number of nursing home days, so really it reduced costs,” Cohen said. “Beyond six months, things really evened out as you would expect once the full recovery process had been completed.”

For both analyses, Cohen and colleagues used a cost-effectiveness threshold of $50,000 per quality-adjusted life year gained. Every data point met that standard, Cohen reported.

“The probability that (TAVR) is economically dominant—saving money and saving lives—is 97 percent and the probability that it is cost-effective at an accepted threshold in the United States is 100 percent,” he said.

Duane S. Pinto, MD, MPH, with Beth Israel Deaconess Medical Center in Boston, pointed out these analyses only showed cost-savings for the U.S. healthcare system.

“The hospital doesn’t necessarily reap this reward because it really depends on the reimbursement for the TAVR,” he said. “It may be saving money for society, but we may not necessarily be making money for the hospital.”

However, Cohen predicted the lower rate of 90-day complications observed with TAVR could benefit hospitals that have reimbursement incentives for reducing rehospitalizations.

“If they’re in a bundled payment (model) … 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.”