Cost–Utility Analysis of Transcatheter Aortic Valve Implantation versus Surgery in High-Risk Severe Aortic Stenosis Patients in Thailand

Q: What is the clinical evidence from this study?

Population: Severe aortic stenosis with high surgical risk. Intervention: Transcatheter Aortic Valve Implantation vs. Surgical Aortic Valve Replacement. Primary outcome: Incremental Cost-Effectiveness Ratio (ICER) per Quality-Adjusted Life-Year (QALY) gained from a societal perspective (ICER THB 1,196,191/QALY).

Unchalee Permsuwan; Voratima Yoodee; Wacin Buddhari; Nattawut Wongpraparut; Tasalak Thonghong; Sirichai Cheewatanakornkul; Krissada Meemook; Pranya Sakiyalak; Pongsanae Duangpakdee; Jirawit Yadee

doi:10.2147/ceor.s371417

July 1, 2022ClinicoEconomics and Outcomes ResearchOpen Access

Cost–Utility Analysis of Transcatheter Aortic Valve Implantation versus Surgery in High-Risk Severe Aortic Stenosis Patients in Thailand

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Key result

TAVI is not cost-effective compared to SAVR for high-risk severe aortic stenosis in Thailand.

ICER THB 1,196,191/QALY

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Why the study?

TAVI is effective in high-risk severe symptomatic AS patients, but its cost-utility compared with SAVR was not established in Thailand.

Is TAVI cost-effective compared to SAVR in 80-year-old patients with severe aortic stenosis and high surgical risk in Thailand?

Key Points

To evaluate the cost-utility of transcatheter aortic valve implantation (TAVI) compared with surgical aortic valve replacement (SAVR) for severe aortic stenosis patients at high surgical risk in Thailand.
Constructed a two-part model to estimate lifetime costs and quality-adjusted life years (QALYs) from societal and healthcare system perspectives for 80-year-old severe aortic stenosis patients at high surgical risk.
Extracted clinical mortality and complication rates from landmark trials (PARTNER Cohort A and CoreValve), and obtained cost and utility inputs from Thai patients across five university-affiliated hospitals, discounted at 3% annually (2021 values).
From a societal perspective, TAVI incurred higher costs (THB 1,551,895 [USD 47,371.64] vs THB 548,438 [USD 16,741.09]) and produced more QALYs (3.15 vs 2.31) than SAVR, yielding an ICER of THB 1,196,191/QALY (USD 36,513.78 QALY).
From a healthcare system perspective, TAVI resulted in higher total costs than SAVR (THB 1,451,317 [USD 44,301.49] vs THB 432,398 [USD 13,198.95]), generating an ICER of THB 1,214,624/QALY (USD 37,076.42/QALY).
Both ICERs substantially exceeded the Thai willingness-to-pay threshold of THB 160,000/QALY (USD 4884/QALY); achieving cost-effectiveness required reducing the TAVI valve cost to THB 199,655 (USD 6094.47).

Structured PICO

Is TAVI cost-effective compared to SAVR in 80-year-old patients with severe aortic stenosis and high surgical risk in Thailand?

P

Population

Simulated cohort of 80-year-old patients in Thailand with severe symptomatic aortic stenosis and high surgical risk undergoing lifetime cost-utility analysis.

I

Intervention

Transcatheter Aortic Valve Implantation (TAVI)

C

Comparator

Surgical Aortic Valve Replacement (SAVR)

O

Outcome

Incremental cost-effectiveness ratio (ICER) per QALY gained from societal and healthcare perspectives over a lifetime horizon

Main Result

Effect estimate: ICER THB 1,196,191/QALY

TAVI provides more QALYs but is not cost-effective compared to SAVR for high-risk severe aortic stenosis in Thailand at current device prices.

Limitations

Modeled using clinical outcomes from PARTNER Cohort A and CoreValve trials rather than local Thai patient outcomes
1-year outcomes were carried forward for long-term extrapolation due to lack of long-term data
Did not account for potential cost reductions from physician learning curves and experience gain
Did not estimate the overall economic burden due to TAVI in Thailand (lacks budget impact analysis)
Modeled using clinical outcomes from PARTNER Cohort A and CoreValve trials rather than Thailand's local patient outcomes
Long-term clinical outcome extrapolation assumed 1-year outcomes carried forward
Did not model the learning curve and experience gain of interventional cardiologists which might lower TAVI costs over time

Implication

TAVI exceeds Thailand's cost-effectiveness threshold versus SAVR in high-risk aortic stenosis; leaves open price reductions or local trials before adoption.

Abstract

Background: Transcatheter aortic valve implantation (TAVI) has been shown to be effective in treating patients with severe symptomatic AS who are high-risk population for conventional surgical aortic valve replacement (SAVR). This study aimed to evaluate the cost-utility of TAVI compared with SAVR for severe aortic stenosis with high surgical risk in Thailand. Methods: Lifetime costs and quality-adjusted life years (QALYs) from societal and healthcare perspectives were estimated using a two-part constructed model. The study population consisted of 80-year-old severe AS patients with high surgical risk. Mortality and complication rates were obtained from landmark trials. All cost-related and utility data were based on Thai population. Costs and QALYs were discounted at a rate of 3% annually and presented as 2021 values. Incremental cost-effectiveness ratios (ICERs) were computed. Sensitivity analyses were performed both deterministically and probabilistically. Results: The findings from a societal perspective revealed that TAVI treatment was associated with higher cost (THB 1,551,895 [USD 47,371.64] vs THB 548,438 [USD 16,741.09] and higher QALYs than SAVR treatment (3.15 vs 2.31 QALYs). The estimated ICER was THB 1,196,191/QALY (USD 36,513.78 QALY). For the healthcare system perspective, TAVI treatment resulted in a higher total cost than SAVR treatment (THB 1,451,317 [USD 44,301.49] vs THB 432,398 [USD 13,198.95]) with comparable gains in LY and QALYs from a societal perspective. The ICER was calculated to be THB 1,214,624/QALY (USD 37,076.42/QALY). TAVI was not cost-effective at the Thai willingness to pay (WTP) threshold of THB 160,000/QALY (USD 4884/QALY). The model was the most sensitive to changes in TAVI valve cost and TAVI or SAVR treatment utilities. Conclusion: TAVI is not a cost-effective strategy in patients with severe AS who are at high surgical risk when compared to SAVR at the WTP of THB 160,000/QALY (USD 4884/QALY) from the perspectives of society and the healthcare system.

Discussion

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Cite This Study

Permsuwan et al. (2022) studied Severe aortic stenosis with high surgical risk. Transcatheter Aortic Valve Implantation vs. Surgical Aortic Valve Replacement was evaluated on Incremental Cost-Effectiveness Ratio (ICER) per Quality-Adjusted Life-Year (QALY) gained from a societal perspective (ICER THB 1,196,191/QALY). TAVI was not cost-effective compared to SAVR for high-risk severe aortic stenosis in Thailand, yielding an ICER of THB 1,196,191/QALY which exceeds the willingness-to-pay threshold.

synapsesocial.com/papers/6a430fa02932785aadad2996 https://doi.org/10.2147/ceor.s371417

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Cost–Utility Analysis of Transcatheter Aortic Valve Implantation versus Surgery in High-Risk Severe Aortic Stenosis Patients in Thailand

Figures

Key Points

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

Cost–Utility Analysis of Transcatheter Aortic Valve Implantation versus Surgery in High-Risk Severe Aortic Stenosis Patients in Thailand

Figures

Key Points

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

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