Gorav Ailawadi1, Damien J LaPar2, Alan M Speir3, Ravi K Ghanta2, Leora T Yarboro2, Ivan K Crosby2, D Scott Lim4, Mohammed A Quader5, Jeffrey B Rich6. 1. Investigators for the Virginia Cardiac Surgery Quality Initiative; Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia. Electronic address: gorav@virginia.edu. 2. Investigators for the Virginia Cardiac Surgery Quality Initiative; Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia. 3. Investigators for the Virginia Cardiac Surgery Quality Initiative; Department of Cardiothoracic Surgery, Inova Heart and Vascular Center, Falls Church, Virginia. 4. Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia. 5. Investigators for the Virginia Cardiac Surgery Quality Initiative; Division of Cardiothoracic Surgery, Department of Surgery, Virginia Commonwealth University, Richmond, Virginia. 6. Investigators for the Virginia Cardiac Surgery Quality Initiative; Department of Cardiothoracic Surgery, Sentara Heart Hospital, Norfolk, Virginia.
Abstract
BACKGROUND: The Placement of Aortic Transcatheter Valve (PARTNER) trial suggested an economic advantage for transcatheter aortic valve replacement (TAVR) for high-risk patients. The purpose of this study was to evaluate the cost effectiveness of TAVR in the "real world" by comparing TAVR with surgical aortic valve replacement (SAVR) in intermediate-risk and high-risk patients. METHODS: A multiinstitutional database of The Society of Thoracic Surgeons (STS) (2011 to 2013) linked with estimated cost data was evaluated for isolated TAVR and SAVR operations (n = 5,578). TAVR-treated patients (n = 340) were 1:1 propensity matched with SAVR-treated patients (n = 340). Patients undergoing SAVR were further stratified into intermediate-risk (SAVR-IR: predicted risk of mortality [PROM] 4% to 8%) and high-risk (SAVR-HR: PROM >8%) cohorts. RESULTS: Median STS PROM for TAVR was 6.32% compared with 6.30% for SAVR (SAVR-IR 4.6% and SAVR-HR 12.4%). A transfemoral TAVR approach was most common (61%). Mortality was higher for TAVR (10%) compared with SAVR (6%, p < 0.047), whereas the SAVR group accrued higher major morbidity (27% vs 14%, p < 0.001) and longer postoperative hospital duration (7 days vs 6 days, p < 0.001). Importantly, TAVR incurred twice the median total costs compared with SAVR ($69,921 vs $33,598, p < 0.001). The increased cost of TAVR was largely driven by the cost of the valve (all p < 0.001). Intermediate-risk patients undergoing SAVR demonstrated the most exaggerated cost savings versus TAVR. CONCLUSIONS: TAVR was associated with greater total costs and mortality compared with SAVR in intermediate-risk and high-risk patients while conferring lower major morbidity and improved resource use. Increased cost of TAVR appears largely related to the cost of the valve. Until the price of TAVR valves decreases, these data suggest that TAVR may not provide the most cost-effective strategy, particularly for intermediate-risk patients.
BACKGROUND: The Placement of Aortic Transcatheter Valve (PARTNER) trial suggested an economic advantage for transcatheter aortic valve replacement (TAVR) for high-risk patients. The purpose of this study was to evaluate the cost effectiveness of TAVR in the "real world" by comparing TAVR with surgical aortic valve replacement (SAVR) in intermediate-risk and high-risk patients. METHODS: A multiinstitutional database of The Society of Thoracic Surgeons (STS) (2011 to 2013) linked with estimated cost data was evaluated for isolated TAVR and SAVR operations (n = 5,578). TAVR-treated patients (n = 340) were 1:1 propensity matched with SAVR-treated patients (n = 340). Patients undergoing SAVR were further stratified into intermediate-risk (SAVR-IR: predicted risk of mortality [PROM] 4% to 8%) and high-risk (SAVR-HR: PROM >8%) cohorts. RESULTS: Median STS PROM for TAVR was 6.32% compared with 6.30% for SAVR (SAVR-IR 4.6% and SAVR-HR 12.4%). A transfemoral TAVR approach was most common (61%). Mortality was higher for TAVR (10%) compared with SAVR (6%, p < 0.047), whereas the SAVR group accrued higher major morbidity (27% vs 14%, p < 0.001) and longer postoperative hospital duration (7 days vs 6 days, p < 0.001). Importantly, TAVR incurred twice the median total costs compared with SAVR ($69,921 vs $33,598, p < 0.001). The increased cost of TAVR was largely driven by the cost of the valve (all p < 0.001). Intermediate-risk patients undergoing SAVR demonstrated the most exaggerated cost savings versus TAVR. CONCLUSIONS: TAVR was associated with greater total costs and mortality compared with SAVR in intermediate-risk and high-risk patients while conferring lower major morbidity and improved resource use. Increased cost of TAVR appears largely related to the cost of the valve. Until the price of TAVR valves decreases, these data suggest that TAVR may not provide the most cost-effective strategy, particularly for intermediate-risk patients.
Authors: Lily E Johnston; Emily A Downs; Robert B Hawkins; Mohammed A Quader; Alan M Speir; Jeffrey B Rich; Ravi K Ghanta; Leora T Yarboro; Gorav Ailawadi Journal: Ann Thorac Surg Date: 2017-06-11 Impact factor: 4.330
Authors: Jared P Beller; Elizabeth D Krebs; Robert B Hawkins; J Hunter Mehaffey; Mohammed A Quader; Alan M Speir; Andy C Kiser; Mark Joseph; Leora T Yarboro; Nicholas R Teman; Gorav Ailawadi Journal: J Thorac Cardiovasc Surg Date: 2019-09-28 Impact factor: 5.209
Authors: Emmanuel Villa; Margherita Dalla Tomba; Antonio Messina; Andrea Trenta; Federico Brunelli; Marco Cirillo; Zean Mhagna; Giovanni Alfonso Chiariello; Giovanni Troise Journal: Cardiol J Date: 2018-09-20 Impact factor: 2.737
Authors: Fahad Alqahtani; Sami Aljohani; Khaled Boobes; Elad Maor; Assem Sherieh; Charanjit S Rihal; David R Holmes; Mohamad Alkhouli Journal: Am J Med Date: 2017-06-14 Impact factor: 4.965
Authors: Robert B Hawkins; J Hunter Mehaffey; Emily A Downs; Lily E Johnston; Leora T Yarboro; Clifford E Fonner; Alan M Speir; Jeffrey B Rich; Mohammed A Quader; Gorav Ailawadi; Ravi K Ghanta Journal: Ann Thorac Surg Date: 2017-06-06 Impact factor: 4.330
Authors: Jared P Beller; William Z Chancellor; J Hunter Mehaffey; Robert B Hawkins; Matthew R Byler; Alan M Speir; Mohammed A Quader; Andy C Kiser; Leora T Yarboro; Gorav Ailawadi; Nicholas R Teman Journal: Ann Thorac Surg Date: 2020-02-11 Impact factor: 4.330
Authors: Jared P Beller; Robert B Hawkins; J Hunter Mehaffey; William Z Chancellor; Clifford E Fonner; Alan M Speir; Mohammed A Quader; Jeffrey B Rich; Leora T Yarboro; Nicholas R Teman; Gorav Ailawadi Journal: J Thorac Cardiovasc Surg Date: 2019-02-11 Impact factor: 5.209
Authors: Robert B Hawkins; Matthew Byler; Clifford Fonner; Irving L Kron; Leora T Yarboro; Alan M Speir; Mohammed A Quader; Gorav Ailawadi; J Hunter Mehaffey Journal: J Card Surg Date: 2019-08-02 Impact factor: 1.620
Authors: Eric J Charles; J Hunter Mehaffey; Robert B Hawkins; Clifford E Fonner; Leora T Yarboro; Mohammed A Quader; Andy C Kiser; Jeffrey B Rich; Alan M Speir; Irving L Kron; Margaret C Tracci; Gorav Ailawadi Journal: Ann Thorac Surg Date: 2019-01-22 Impact factor: 4.330