Advertisement

Estimating the additional costs per life saved due to transcatheter aortic valve replacement: a secondary data analysis of electronic health records in Germany

  • Klaus Kaier
  • Constantin von zur Mühlen
  • Andreas Zirlik
  • Wolfgang Bothe
  • Philip Hehn
  • Manfred Zehender
  • Christoph Bode
  • Peter StachonEmail author
Original Paper

Abstract

Aortic stenosis (AS) is the most common valvular heart disease, with a dismal prognosis when untreated. Recommended therapy is surgical (SAVR) or transcatheter (TAVR) aortic valve replacement. Based on a retrospective cohort of isolated SAVR and TAVR procedures performed in Germany in 2015 (N = 17,826), we examine the impact of treatment selection on in-hospital mortality and total in-hospital costs for a variety of at-risk populations. Since patients were not randomized to the two treatment options, the two endpoints in-hospital mortality and reimbursement are analyzed using logistic and linear regression models with 20 predefined patient characteristics as potential confounders. Incremental cost-effectiveness ratios were calculated as a ratio of the risk-adjusted reimbursement and mortality differences with 95% confidence intervals obtained by Fieller’s theorem. Our study shows that TF-TAVR is more costly that SAVR and that cost differences between the procedures vary little between patient groups. Results regarding in-hospital mortality are mixed. SAVR is the predominant procedure among younger patients. For patients older than 85 years or at intermediate and higher pre-operative risk TF-TAVR seems to be the treatment of choice. Incremental cost-effectiveness ratios (ICER) are most favorable for patients older than 85 years (ICER €154,839, 95% CI €89,163–€302,862), followed by patients at higher pre-operative risk (ICER €413,745, 95% CI €258,027–€952,273). A hypothetical shift from SAVR towards TF-TAVR among patients at intermediate pre-operative risk is associated with a less favorable ICER (€1,486,118, 95% CI €764,732–€23,692,323), as the risk-adjusted mortality benefit is relatively small (− 0.97% point), while the additional reimbursement is still eminent (+€14,464). From a German healthcare system payer’s perspective, the additional costs per life saved due to TAVR are most favorable for patients older than 85 and/or at higher pre-operative risk.

Keywords

Transcatheter aortic valve replacement Surgical aortic valve replacement Cost ICER 

Notes

Compliance with ethical standards

Conflict of interest

The authors declare that they have no competing interests.

Supplementary material

10198_2018_1023_MOESM1_ESM.pdf (43 kb)
Supplementary material 1 (PDF 42 KB)

References

  1. 1.
    Andell, P., Li, X., Martinsson, A., et al.: Epidemiology of valvular heart disease in a Swedish nationwide hospital-based register study. Heart. 103, 1696 (2017).  https://doi.org/10.1136/heartjnl-2016-310894 CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Varadarajan, P., Kapoor, N., Bansal, R.C., et al.: Clinical profile and natural history of 453 nonsurgically managed patients with severe aortic stenosis. Ann. Thorac. Surg. 82, 2111–2115 (2006).  https://doi.org/10.1016/j.athoracsur.2006.07.048 CrossRefPubMedGoogle Scholar
  3. 3.
    Nishimura, R.A., Otto, C.M., Bonow, R.O., et al.: 2014 AHA/ACC guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association task force on practice guidelines. Circulation. 129, 2440–2492 (2014).  https://doi.org/10.1161/CIR.0000000000000029 CrossRefPubMedGoogle Scholar
  4. 4.
    Foroutan, F., Guyatt, G.H., O’Brien, K., et al.: Prognosis after surgical replacement with a bioprosthetic aortic valve in patients with severe symptomatic aortic stenosis: systematic review of observational studies. BMJ 2016;:i5065.  https://doi.org/10.1136/bmj.i5065
  5. 5.
    Thyregod, H.G.H., Steinbrüchel, D.A., Ihlemann, N., et al.: Transcatheter versus surgical aortic valve replacement in patients with severe aortic valve stenosis. J. Am. Coll. Cardiol. 65, 2184–2194 (2015).  https://doi.org/10.1016/j.jacc.2015.03.014 CrossRefPubMedGoogle Scholar
  6. 6.
    Mack, M.J., Leon, M.B., Smith, C.R., et al.: 5-year outcomes of transcatheter aortic valve replacement or surgical aortic valve replacement for high surgical risk patients with aortic stenosis (PARTNER 1): a randomised controlled trial. Lancet. 385, 2477–2484 (2015).  https://doi.org/10.1016/S0140-6736(15)60308-7 CrossRefPubMedGoogle Scholar
  7. 7.
    Daubert, M.A., Weissman, N.J., Hahn, R.T., et al.: Long-term valve performance of TAVR and SAVR. JACC Cardiovasc. Imaging. 10, 15–25 (2017).  https://doi.org/10.1016/j.jcmg.2016.11.004 CrossRefGoogle Scholar
  8. 8.
    Siemieniuk, R.A., Agoritsas, T., Manja, V., et al.: Transcatheter versus surgical aortic valve replacement in patients with severe aortic stenosis at low and intermediate risk: systematic review and meta-analysis. BMJ 2016;:i5130.  https://doi.org/10.1136/bmj.i5130
  9. 9.
    Reynolds, M.R., Lei, Y., Wang, K., et al.: Cost-effectiveness of transcatheter aortic valve replacement with a self-expanding prosthesis versus surgical aortic valve replacement. J. Am. Coll. Cardiol. 67, 29–38 (2016).  https://doi.org/10.1016/j.jacc.2015.10.046 CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Gargiulo, G., Sannino, A., Capodanno, D., et al.: Transcatheter aortic valve implantation versus surgical aortic valve replacement: a systematic review and meta-analysis. Ann. Intern. Med. 165, 334 (2016).  https://doi.org/10.7326/M16-0060 CrossRefPubMedGoogle Scholar
  11. 11.
    Piazza, N., Kalesan, B., van Mieghem, N., et al.: A 3-center comparison of 1-year mortality outcomes between transcatheter aortic valve implantation and surgical aortic valve replacement on the basis of propensity score matching among intermediate-risk surgical patients. JACC Cardiovasc. Interv. 6, 443–451 (2013).  https://doi.org/10.1016/j.jcin.2013.01.136 CrossRefPubMedGoogle Scholar
  12. 12.
    D’Errigo, P., Barbanti, M., Ranucci, M., et al.: Transcatheter aortic valve implantation versus surgical aortic valve replacement for severe aortic stenosis: results from an intermediate risk propensity-matched population of the Italian OBSERVANT study. Int. J. Cardiol. 167, 1945–1952 (2013).  https://doi.org/10.1016/j.ijcard.2012.05.028 CrossRefPubMedGoogle Scholar
  13. 13.
    Leon, M.B., Smith, C.R., Mack, M.J., et al.: Transcatheter or surgical aortic-valve replacement in intermediate-risk patients. N. Engl. J. Med. 374, 1609–1620 (2016).  https://doi.org/10.1056/NEJMoa1514616 CrossRefPubMedGoogle Scholar
  14. 14.
    Rosato, S., Santini, F., Barbanti, M., et al.: Transcatheter aortic valve implantation compared with surgical aortic valve replacement in low-risk patients. Circ. Cardiovasc. Interv. 9, e003326 (2016).  https://doi.org/10.1161/CIRCINTERVENTIONS.115.003326 CrossRefPubMedGoogle Scholar
  15. 15.
    Sinzobahamvya, N., Kopp, T., Arenz, C., et al.: Reimbursement by current German diagnosis-related groups system penalises complex congenital heart surgery. Cardiol Young. 24, 344–350 (2014).  https://doi.org/10.1017/S1047951113000437 CrossRefPubMedGoogle Scholar
  16. 16.
    Qvick, B., Buehren, V., Woltmann, A.: Ist ein Polytrauma heutzutage noch bezahlbar? G-DRG-System vs. Tagessätze anhand 1030 polytraumatisierter Patienten. Unfallchirurg. 115, 892–896 (2012).  https://doi.org/10.1007/s00113-010-1920-7 CrossRefPubMedGoogle Scholar
  17. 17.
    Bauer, M., Ostermann, H.: DRGs in transfusion medicine and hemotherapy in Germany. Transfus Med Hemotherapy. 39, 60–66 (2012).  https://doi.org/10.1159/000337337 CrossRefGoogle Scholar
  18. 18.
    Schreyögg, J., Tiemann, O., Busse, R.: Cost accounting to determine prices: how well do prices reflect costs in the German DRG-system? Health Care Manag. Sci. 9, 269–279 (2006).  https://doi.org/10.1007/s10729-006-9094-0 CrossRefPubMedGoogle Scholar
  19. 19.
    Hoehn, T., Drabik, A., Lehmann, C., et al.: Correlation between severity of disease and reimbursement of costs in neonatal and paediatric intensive care patients. Acta Paediatr. 97, 1438–1442 (2008).  https://doi.org/10.1111/j.1651-2227.2008.00926.x CrossRefPubMedGoogle Scholar
  20. 20.
    Vogl, M.: Assessing DRG cost accounting with respect to resource allocation and tariff calculation: the case of Germany. Health Econ. Rev. 2, 15 (2012).  https://doi.org/10.1186/2191-1991-2-15 CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Malyar, N., Furstenberg, T., Wellmann, J., et al.: Recent trends in morbidity and in-hospital outcomes of in-patients with peripheral arterial disease: a nationwide population-based analysis. Eur. Heart J. 34, 2706–2714 (2013).  https://doi.org/10.1093/eurheartj/eht288 CrossRefPubMedGoogle Scholar
  22. 22.
    Freisinger, E., Fuerstenberg, T., Malyar, N.M., et al.: German nationwide data on current trends and management of acute myocardial infarction: discrepancies between trials and real-life. Eur. Heart J. 35, 979–988 (2014)CrossRefGoogle Scholar
  23. 23.
    Kaier, K., Reinecke, H., Naci, H., et al.: The impact of post-procedural complications on reimbursement, length of stay and mechanical ventilation among patients undergoing transcatheter aortic valve implantation in Germany. Eur. J. Health Econ. 1–6 (2017)Google Scholar
  24. 24.
    Reinöhl, J., Kaier, K., Reinecke, H., et al.: Effect of availability of transcatheter aortic valve replacement on clinical practice. N. Engl. J. Med. 373, 2438–2447 (2015)CrossRefGoogle Scholar
  25. 25.
    Reinöhl, J., Kaier, K., Reinecke, H., et al.: Effect of availability of transcatheter aortic valve replacement on clinical practice: supplementary appendix. N. Engl. J. Med. 373, 2438–2447 (2015)CrossRefGoogle Scholar
  26. 26.
    Fieller, E.C.: Some problems in interval estimation. J. R. Stat. Soc. Ser. B Methodol. 175–85 (1954)Google Scholar
  27. 27.
    Zack, C.J., Al-Qahtani, F., Kawsara, A., et al.: Comparative outcomes of surgical and transcatheter aortic valve replacement for aortic stenosis in Nonagenarians. Am. J. Cardiol. 119, 893–899 (2017).  https://doi.org/10.1016/j.amjcard.2016.11.045 CrossRefPubMedGoogle Scholar
  28. 28.
    Sponga, S., Isola, M., Bagur, R., et al.: Transcatheter aortic valve implantation versus surgical aortic valve replacement in patients over 85 years old. Interact. Cardiovasc. Thorac. Surg. Published Online First: 16 June 2017. (2017).  https://doi.org/10.1093/icvts/ivx180 CrossRefPubMedGoogle Scholar
  29. 29.
    Adams, D.H., Popma, J.J., Reardon, M.J., et al.: Transcatheter aortic-valve replacement with a self-expanding prosthesis. N. Engl. J. Med. 370, 1790–1798 (2014)CrossRefGoogle Scholar
  30. 30.
    Gurvitch, R., Tay, E.L., Wijesinghe, N., et al.: Transcatheter aortic valve implantation: lessons from the learning curve of the first 270 high-risk patients. Catheter. Cardiovasc. Interv. 78, 977–984 (2011).  https://doi.org/10.1002/ccd.22961 CrossRefPubMedGoogle Scholar
  31. 31.
    Lunardi, M., Pesarini, G., Zivelonghi, C., et al.: Clinical outcomes of transcatheter aortic valve implantation: from learning curve to proficiency. Open Heart. 3, e000420 (2016).  https://doi.org/10.1136/openhrt-2016-000420 CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Klaus Kaier
    • 1
    • 2
  • Constantin von zur Mühlen
    • 2
  • Andreas Zirlik
    • 2
    • 4
  • Wolfgang Bothe
    • 3
  • Philip Hehn
    • 1
  • Manfred Zehender
    • 2
  • Christoph Bode
    • 2
  • Peter Stachon
    • 2
    Email author return OK on get
  1. 1.Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical CenterUniversity of FreiburgFreiburgGermany
  2. 2.Department of Cardiology and Angiology I, Heart Center Freiburg, Faculty of MedicineUniversity of FreiburgFreiburgGermany
  3. 3.Department of Cardiac and Vascular Surgery, Heart Center Freiburg, Faculty of MedicineUniversity of FreiburgFreiburgGermany
  4. 4.Department of CardiologyMedical University of GrazGrazAustria

Personalised recommendations