Post-TAVR pacemakers linked to higher mortality but similar healthcare costs

Patients who required permanent pacemakers (PPMs) after transcatheter aortic valve replacement (TAVR) demonstrated lower survival rates and higher comorbidity burdens over a multiyear follow-up. However, they didn’t accumulate significantly greater healthcare costs, according to a study published online May 25 in JAMA Network Open.

Lead author Talal Aljabbary, MD, MSc, and colleagues used a 10-hospital registry to study 1,263 patients who were discharged alive following TAVR in Ontario, Canada, from April 2010 through March 2015. The patients were 82.3 years old on average, 52.9 percent male and 14.7 percent required PPM implantation during the index hospitalization.

After propensity-score weighting to balance the groups and following the patients for an average of 2.7 years, the researchers found:

  • 43.9 percent of patients in the PPM group died during follow-up, compared to 31.7 percent of patients who didn’t require pacemakers.
  • 80.9 percent of PPM patients were readmitted for any cause and 95.5 percent visited the emergency department. The corresponding values for non-PPM patients were 70.6 percent and 87.3 percent, respectively.
  • Pacemaker patients were almost twice as likely to be readmitted for heart failure (33.9 percent versus 19.1 percent).

The researchers acknowledged they couldn’t define the mechanisms that contributed to the worse outcomes among the PPM group but suggested pacing-induced cardiomyopathy, device-related complications or infections and an increased incidence of myocardial fibrosis—“which may predispose these patients to heart failure and sudden cardiac arrest from ventricular arrhythmias”—could have played a role.

But despite being an apparently sicker population more likely to require repeat hospital visits, the between-group differences in cumulative health care costs after discharge weren’t statistically significant (cost ratio: 1.18). One-year mean and median costs were $38,310 and $23,566, respectively, for the PPM group and $34,254 and $18,108 for the non-pacemaker patients.

“We postulate that this lack of statistical significance may be due to our study being underpowered given the wide variation associated with cost data; alternatively, it may be due to the increased mortality in the PPM group, which reduced the overall follow-up on average for patients with a PPM, and thus cumulative costs,” Aljabbary et al. wrote.

As has been the case in previous studies of TAVR healthcare costs, the main driver of post-discharge costs was repeat hospitalizations. The authors also assessed patients’ costs for continuing care, outpatient care, physician costs and medication expenses, but didn’t include the cost of the initial hospitalization in their analysis.

Aljabbary et al. said their study was limited by its observational design and the lack of baseline information on conduction abnormalities or the presence of atrial fibrillation. They also pointed out the cost differences would have been greater if they included the index hospitalization in their calculations because patients requiring a PPM had an average length of stay 4.4 days longer after TAVR.