Aida Ribera1,2, John Slof3, Ignacio Ferreira-González4,5, Vicente Serra2, Bruno García-Del Blanco6, Purificació Cascant1, Rut Andrea6, Carlos Falces6, Enrique Gutiérrez7, Raquel Del Valle-Fernández8, César Morís-de laTassa8, Pedro Mota9, Juan Francisco Oteo10, Pilar Tornos2, David García-Dorado2. 1. Cardiovascular Clinical Epidemiology Unit, Cardiology Department, University Hospital Vall d'Hebron, Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Pg. Vall d'Hebron, 119-129, 08035, Barcelona, Spain. 2. Cardiology Department (CIBERCV), University Hospital Vall d'Hebron, Pg. Vall d'Hebron, 119-129, 08035, Barcelona, Spain. 3. Department of Business, Universitat Autònoma de Barcelona, B2, Av. de l'Eix Central, s/n, 08193 Cerdanyola del Vallès, Barcelona, Spain. 4. Cardiovascular Clinical Epidemiology Unit, Cardiology Department, University Hospital Vall d'Hebron, Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Pg. Vall d'Hebron, 119-129, 08035, Barcelona, Spain. nachoferreira@secardiologia.es. 5. Cardiology Department (CIBERCV), University Hospital Vall d'Hebron, Pg. Vall d'Hebron, 119-129, 08035, Barcelona, Spain. nachoferreira@secardiologia.es. 6. Cardiology Department, Thorax Institute, Hospital Clinic, IDIBAPS, University of Barcelona, Carrer de Villarroel, 170, 08036, Barcelona, Spain. 7. Cardiology Department, Departamento de Medicina, Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense, Calle del Dr. Esquerdo, 46, 28007, Madrid, Spain. 8. Unidad de Hemodinamica y Cardiología Intervencionista, Area del Corazón, Hospital Universitario Central de Asturias, Av. De Roma, 33011, Oviedo, Asturias, Spain. 9. Servicio de Cardiología, ICICOR, Hospital Clínico Universitario, Av. Ramón y Cajal, 3, 47003, Valladolid, Spain. 10. Servicio de Cardiología, Hospital Puerta de Hierro, C/Manuel de Falla, 1, Majadahonda, 28222, Madrid, Spain.
Abstract
OBJECTIVES: The economic crisis in Europe might have limited access to some innovative technologies implying an increase of waiting time. The purpose of the study is to evaluate the impact of waiting time on the costs and benefits of transcatheter aortic valve replacement (TAVR) for the treatment of severe aortic stenosis. METHODS: This is a cost-utility analysis from the perspective of the Spanish National Health Service. Results of two prospective hospital registries (158 and 273 consecutive patients) were incorporated into a probabilistic Markov model to compare quality adjusted life years (QALYs) and costs for TAVR after waiting for 3-12 months, relative to immediate TAVR. We simulated a cohort of 1000 patients, male, and 80 years old; other patient profiles were assessed in sensitivity analyses. RESULTS: As waiting time increased, costs decreased at the expense of lower survival and loss of QALYs, leading to incremental cost-effectiveness ratios for eliminating waiting lists of about 12,500 € per QALY. In subgroup analyses prioritization of patients for whom higher benefit was expected led to a smaller loss of QALYs. Concerning budget impact, long waiting lists reduced spending considerably and permanently. CONCLUSIONS: A shorter waiting time is likely to be cost-effective (considering commonly accepted willingness-to-pay thresholds in Europe) relative to 3 months or longer waiting periods. If waiting lists are nevertheless seen as unavoidable due to severe but temporary budgetary restrictions, prioritizing patients for whom higher benefit is expected appears to be a way of postponing spending without utterly sacrificing patients' survival and quality of life.
OBJECTIVES: The economic crisis in Europe might have limited access to some innovative technologies implying an increase of waiting time. The purpose of the study is to evaluate the impact of waiting time on the costs and benefits of transcatheter aortic valve replacement (TAVR) for the treatment of severe aortic stenosis. METHODS: This is a cost-utility analysis from the perspective of the Spanish National Health Service. Results of two prospective hospital registries (158 and 273 consecutive patients) were incorporated into a probabilistic Markov model to compare quality adjusted life years (QALYs) and costs for TAVR after waiting for 3-12 months, relative to immediate TAVR. We simulated a cohort of 1000 patients, male, and 80 years old; other patient profiles were assessed in sensitivity analyses. RESULTS: As waiting time increased, costs decreased at the expense of lower survival and loss of QALYs, leading to incremental cost-effectiveness ratios for eliminating waiting lists of about 12,500 € per QALY. In subgroup analyses prioritization of patients for whom higher benefit was expected led to a smaller loss of QALYs. Concerning budget impact, long waiting lists reduced spending considerably and permanently. CONCLUSIONS: A shorter waiting time is likely to be cost-effective (considering commonly accepted willingness-to-pay thresholds in Europe) relative to 3 months or longer waiting periods. If waiting lists are nevertheless seen as unavoidable due to severe but temporary budgetary restrictions, prioritizing patients for whom higher benefit is expected appears to be a way of postponing spending without utterly sacrificing patients' survival and quality of life.
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