Cost-effectiveness of transcatheter versus surgical aortic valve replacement in patients at lower surgical risk: results from the NOTION trial.

Benjamin P Geisler, Troels H Jørgensen, Hans Gustav H Thyregod, Jan Benjamin Pietzsch, Lars Søndergaard

To estimate the cost-effectiveness of transcatheter aortic valve implantation (TAVI) vs surgical aortic valve replacement (SAVR) in patients at lower surgical risk. Discounted costs from a societal perspective and effectiveness as quality-adjusted life years (QALYs) were projected to lifetime via a decision-analytic model calibrated to 60-month data from the NOTION trial. The base case assumed a scenario in which any mortality benefit would gradually fade out over time, with other scenarios explored in sensitivity analyses. The incremental cost-effectiveness ratio (ICER) was compared to the country-specific willingness-to-pay (WTP) threshold of 1.13 million Danish kroner (DKK).The base case ICER was DKK696,264/QALY (around €72,100/QALY via purchasing parity adjustment). Variation in long-term mortality beyond 5 years led to limited variation of incremental costs (DKK64,200 to 64,600), but a more pronounced variation in incremental QALYs (0.07 to 0.19 QALYs for most conservative and optimistic assumptions, compared to base case of 0.09 QALYs). All resulting ICERs (range DKK334,200 to DKK904,100 per QALY gained) were below the WTP threshold. TAVI in a cohort of primarily low-surgical-risk patients was found to be a cost-effective treatment strategy in the Danish healthcare system. Cost-effectiveness analyses in other settings are warranted as are registries given the sensitivity of the model to long-term mortality.