No-frills TAVR may offset cost pressures in mid-risk patients

CHICAGO—In order to be cost-effective in intermediate-risk patients, transcatheter aortic valve replacement (TAVR) procedures will need to be stripped down to the necessities in uncomplicated cases, according to one of TAVR’s leading health economists.  

“TAVR is already reasonably cost effective for many patients who are at extreme and high risk,” David Cohen, MD, MSc, director of cardiovascular research at St. Luke’s Mid America Heart Institute in Kansas City, Mo., said June 4 at the Transcatheter Valve Therapies conference in Chicago. “But the cost effectiveness of TAVR for the intermediate-risk patients is less certain and likely will depend on achieving substantial cost reductions from historical levels.”

Cohen and others have conducted numerous studies on the cost effectiveness of TAVR in inoperable or extreme high-risk as well as high-risk patients with severe aortic stenosis implanted with devices from Edwards Lifesciences and Medtronic. Overall the results favored TAVR, showing that gains in life expectancy trumped the high costs of the devices and procedures.

“The valves cost about six times as much as any comparable surgical valves,” he pointed out. “For patients who are now being considered for TAVR, like intermediate-risk patients, there frankly are probably less expensive ways of doing it alternatively.”

In addition, TAVR is not expected to show a dramatic survival benefit over surgery in intermediate- or lower-risk patients, putting even more of a squeeze on its cost-effectiveness. If benefits remain similar, then cost becomes critical.

He broke the cost of TAVR into three components: the cost of the devices, the cost of complications and the cost of “everything else.”

“The everything else is where we have the biggest opportunity to lower the cost of these procedures,” Cohen said. “Complications account for about 24 percent of the nonimplant costs but the rest of it is all the everything else.”

Operators and hospitals can reduce costs by eliminating preventable complications such as renal failure or bleeding. Previously Cohen’s team had shown that renal failure can add more than $68,000 to a case, but it is relatively uncommon. Major bleeding, while less costly, is twice as frequent as renal failure and can tag on $3,238 to attributable costs.

Cohen cited research on a minimalist approach for elective TAVRs from Emory University Hospital in Atlanta. The team used a cardiac catheterization laboratory rather than a hybrid operating room, local anesthesia rather than general anesthesia, percutaneous access and closure, minimal conscious sedation and transthoracic echocardiography.

Excluding the cost of the valve, they saved about $10,000 per case without compromising 30-day or one-year survival. “If you take the valve off the top of that, you can see they about halved the cost of the hospitalization by getting rid of all the bells and whistles that are not really required,” Cohen said.

Saint Luke’s Mid America initiated a minimalist approach for suitable patients in its TAVR program two months ago. Cohen added that his research group will collaborate with colleagues in the Multidisciplinary, Multimodality but Minimalist (3M) TAVR study to provide a cost-effectiveness analysis.