Evaluation of PARTNER II Compares Cost-Effectiveness of TAVR and SAVR

February 19, 2019—Findings from an evaluation of the cost-effectiveness of transcatheter aortic valve replacement (TAVR) versus surgical aortic valve replacement (SAVR) in intermediate-risk patients with severe aortic stenosis (AS) in the PARTNER II trial were published by Suzanne J. Baron, MD, et al in Circulation (2018;139:877–888).

The background of the study is that although TAVR and SAVR resulted in similar rates of death or stroke at 2 years for intermediate-risk patients with severe AS, the comparative cost-effectiveness of the two approaches remains uncertain, noted the investigators.

As summarized in Circulation, there were 3,110 intermediate-risk AS patients treated with TAVR or SAVR in the PARTNER II trial between 2011 and 2014. A total of 2,032 patients were randomized to undergo TAVR using Edwards Lifesciences' Sapien XT valve (the XT-TAVR group) or SAVR in the PARTNER IIA trial. The PARTNER S3i trial included an additional 1,078 patients who were treated with TAVR using Edwards' Sapien 3 valve (the S3-TAVR group). The Sapien 3 valve offers a lower delivery profile and sealing skirt designed to reduce paravalvular regurgitation compared with TAVR using the Sapien XT device.

In the study, procedural costs were estimated using measured resource utilization. Other in-trial costs were assessed by linkage of trial data with Medicare claims (n = 2,333) or by linear regression models for unlinked patients (n = 682). Health utilities were estimated using the EuroQoL five dimensions questionnaire at baseline and at 1, 12, and 24 months. Using a Markov model informed by in-trial costs, utilities, and survival data, lifetime cost-effectiveness from the perspective of the United States health care system was estimated in terms of cost per quality-adjusted life-year gained.

The investigators reported that although procedural costs were approximately $20,000 higher with TAVR than SAVR, total cost differences for the index hospitalization were only $2,888 higher with XT-TAVR (P = .014) and were $4,155 lower with S3-TAVR (P < .001), owing to reductions in length of stay with TAVR.

Follow-up costs were significantly lower with XT-TAVR (Δ = −$9,304; P < .001) and S3-TAVR (Δ = −$11,377; P < .001) than with SAVR. Over a lifetime horizon, TAVR was projected to lower total costs by $8,000 to $10,000 and to increase quality-adjusted survival by 0.15 to 0.27 years. XT-TAVR and S3-TAVR were found to be economically dominant compared with SAVR in 84% and 97% of bootstrap replicates, respectively.

The study showed that among intermediate-risk AS patients, TAVR is projected to be economically dominant from the perspective of the United States health care system by providing both greater quality-adjusted life expectancy and lower long-term costs than SAVR. If long-term data demonstrate comparable late mortality between TAVR and SAVR, these findings suggest that TAVR might be the preferred treatment strategy for intermediate-risk AS patients based on both clinical and economic considerations, concluded the investigators in Circulation.