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. 2022 Aug 4;22(1):994.
doi: 10.1186/s12913-022-08369-5.

Cost-effectiveness of transcatheter aortic valve implantation in patients with severe symptomatic aortic stenosis of intermediate surgical risk in Singapore

Rachel Su-En See-Toh #  1 , Xin Yi Wong #  1 , Kush Shiv Kishore Herkshin Mahboobani  1 , Swee Sung Soon  1 , Benjamin Kearns  2 , Katy Cooper  2 , Kay Woon Ho  3 , Ivandito Kuntjoro  4 , Kwong Ng  5
Affiliations

Cost-effectiveness of transcatheter aortic valve implantation in patients with severe symptomatic aortic stenosis of intermediate surgical risk in Singapore

Rachel Su-En See-Toh et al. BMC Health Serv Res. .

Abstract

Objective: The objective was to assess the cost-effectiveness of transcatheter aortic valve implantation (TAVI) in patients with severe aortic stenosis with intermediate surgical risk in Singapore.

Methods: A de novo Markov model with three health states - stroke with long-term sequelae, no stroke, and death - was developed and simulated using Monte Carlo simulations with 10,000 iterations over a five-year time horizon from the Singapore healthcare system perspective. A 3% annual discount rate for costs and outcomes and monthly cycle lengths were used. By applying the longest available published clinical evidence, simulated patients received either TAVI or surgical aortic valve replacement (SAVR) and were at risk of adverse events (AEs) such as moderate-to-severe paravalvular aortic regurgitation (PAR).

Results: When five-year PARTNER 2A data was applied, base-case analyses showed that the incremental cost-effectiveness ratio (ICER) for TAVI compared to SAVR was US$315,760 per quality-adjusted life year (QALY) gained. The high ICER was due to high incremental implantation and procedure costs of TAVI compared to SAVR, and marginal improvement of 0.10 QALYs as simulated mortality of TAVI exceeded SAVR at 3.75 years post-implantation. One-way sensitivity analysis showed that the ICERs were most sensitive to cost of PAR, utility values of SAVR patients, and cost of TAVI and SAVR implants and procedures. When disutilities for AEs were additionally applied, the ICER decreased to US$300,070 per QALY gained. TAVI was dominated by SAVR when the time horizon increased to 20 years. Clinical outcomes projected from one-year PARTNER S3i data further reduced the ICER to US$86,337 per QALY gained for TAVI, assuming early all-cause mortality benefits from TAVI continued to persist. This assumption was undermined when longer term data showed that TAVI's early mortality benefits diminished at five years.

Limitations and conclusion: TAVI is unlikely to be cost-effective in intermediate surgical-risk patients compared to SAVR in Singapore.

Keywords: Cost-effectiveness; Singapore; TAVI; TAVR; Transcatheter aortic valve implantation; Transcatheter aortic valve replacement.

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Conflict of interest statement

H.K. and I.K. received honoraria as speakers from Edwards Lifesciences and Medtronic. All other authors declared no competing interests.

Figures

Fig. 1
Fig. 1
Markov state transition diagram for the economic model. Abbreviations: SAVR, surgical aortic valve replacement; TAVI, transcatheter aortic valve implantation
Fig. 2
Fig. 2
Tornado diagram for deterministic one-way sensitivity analysis (top 10 drivers)
Fig. 3
Fig. 3
Cost effectiveness acceptability curve at varying willingness-to-pay levels for TAVI versus SAVR in intermediate surgical risk patients
See this image and copyright information in PMC

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