Financial Incentives for Transcatheter Aortic Valve Implantation in Ontario, Canada: A Cost-Utility Analysis

• Published in: Journal of the American Heart Association 2022-04, Vol.11 (8), p.e025085-e025085
• Main Authors: Peel, John K, Neves Miranda, Rafael, Naimark, David, Woodward, Graham, Mamas, Mamas A, Madan, Mina, Wijeysundera, Harindra C
• Format: Article
• Language: English
• Subjects: Aortic Valve - surgery; aortic valve stenosis; Aortic Valve Stenosis - etiology; Cost-Benefit Analysis; health care costs; heart valve prosthesis implantation; Heart Valve Prosthesis Implantation - adverse effects; Humans; Motivation; Ontario; Original Research; quality improvement; quality indicators; Transcatheter Aortic Valve Replacement - adverse effects; Treatment Outcome
• ISSN: 2047-9980; 2047-9980
• DOI: 10.1161/JAHA.121.025085

Background Transcatheter aortic valve implantation (TAVI) is a minimally invasive therapy for patients with severe aortic stenosis, which has become standard of care. The objective of this study was to determine the maximum cost-effective investment in TAVI care that should be made at a health system level to meet quality indicator goals. Methods and Results We performed a cost-utility analysis using probabilistic patient-level simulation of TAVI care from the Ontario, Canada, Ministry of Health perspective. Costs and health utilities were accrued over a 2-year time horizon. We created 4 hypothetical strategies that represented TAVI care meeting ≥1 quality indicator targets, (1) reduced wait times, (2) reduced hospital length of stay, (3) reduced pacemaker use, and (4) combined strategy, and compared these with current TAVI care. Per-person costs, quality-adjusted life years, and clinical outcomes were estimated by the model. Using these, incremental net monetary benefits were calculated for each strategy at different cost-effectiveness thresholds between $0 and $100 000 per quality-adjusted life year. Clinical improvements over the current practice were estimated with all comparator strategies. In Ontario, achieving quality indicator benchmarks could avoid ≈26 wait-list deaths and 200 wait-list hospitalizations annually. Compared with current TAVI care, the incremental net monetary benefit for this strategy varied from $10 765 (±$8721) and $17 221 (±$8977). This would translate to an annual investment of between ≈$14 to ≈$22 million by the Ontario Ministry of Health to incentivize these performance measures being cost-effective. Conclusions This study has quantified the modest annual investment required and substantial clinical benefit of meeting improvement goals in TAVI care.