The European Journal of Health Economics

, Volume 19, Issue 7, pp 945–956 | Cite as

The impact of waiting for intervention on costs and effectiveness: the case of transcatheter aortic valve replacement

  • Aida Ribera
  • John Slof
  • Ignacio Ferreira-GonzálezEmail author
  • Vicente Serra
  • Bruno García-del Blanco
  • Purificació Cascant
  • Rut Andrea
  • Carlos Falces
  • Enrique Gutiérrez
  • Raquel del Valle-Fernández
  • César Morís-de laTassa
  • Pedro Mota
  • Juan Francisco Oteo
  • Pilar Tornos
  • David García-Dorado
Original Paper



The economic crisis in Europe might have limited access to some innovative technologies implying an increase of waiting time. The purpose of the study is to evaluate the impact of waiting time on the costs and benefits of transcatheter aortic valve replacement (TAVR) for the treatment of severe aortic stenosis.


This is a cost-utility analysis from the perspective of the Spanish National Health Service. Results of two prospective hospital registries (158 and 273 consecutive patients) were incorporated into a probabilistic Markov model to compare quality adjusted life years (QALYs) and costs for TAVR after waiting for 3–12 months, relative to immediate TAVR. We simulated a cohort of 1000 patients, male, and 80 years old; other patient profiles were assessed in sensitivity analyses.


As waiting time increased, costs decreased at the expense of lower survival and loss of QALYs, leading to incremental cost-effectiveness ratios for eliminating waiting lists of about 12,500 € per QALY. In subgroup analyses prioritization of patients for whom higher benefit was expected led to a smaller loss of QALYs. Concerning budget impact, long waiting lists reduced spending considerably and permanently.


A shorter waiting time is likely to be cost-effective (considering commonly accepted willingness-to-pay thresholds in Europe) relative to 3 months or longer waiting periods. If waiting lists are nevertheless seen as unavoidable due to severe but temporary budgetary restrictions, prioritizing patients for whom higher benefit is expected appears to be a way of postponing spending without utterly sacrificing patients’ survival and quality of life.


Waiting lists Cost-utility Transcatheter aortic valve replacement Aortic stenosis 

JEL Classification

I Health, Education, and Welfare I1 Health I19 Other 



Mar Vila and Joan Sagarra provided costs from the cost accounting records at University Hospital Vall d’Hebron and Hospital Clínic. Josep Ramon Marsal provided statistical advice. Teresa Fernández provided administrative support. Gaietà Permanyer-Miralda and Joan MV Pons contributed to the article drafting and revision. Manuel Castellà, Joaquim Cevallos, Manel Sabaté, Gerald Lébano, Lucía Fernández, Isabel González, and Carolina Álvaro contributed to data collection.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.


Financial support for this study was provided in part by a grant from Instituto de Investigación Carlos III (FIS). The Spanish Ministry of Economy and Competitiveness (Reference number: PI10/00369) and CIBERESP. The funding agreement ensured the authors’ independence in designing the study, interpreting the data, writing, and publishing this report.

Supplementary material

10198_2017_941_MOESM1_ESM.docx (70 kb)
Supplementary material 1 (DOCX 69 kb)


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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2017

Authors and Affiliations

  • Aida Ribera
    • 1
    • 3
  • John Slof
    • 2
  • Ignacio Ferreira-González
    • 1
    • 3
    Email author
  • Vicente Serra
    • 3
  • Bruno García-del Blanco
    • 4
  • Purificació Cascant
    • 1
  • Rut Andrea
    • 4
  • Carlos Falces
    • 4
  • Enrique Gutiérrez
    • 5
  • Raquel del Valle-Fernández
    • 6
  • César Morís-de laTassa
    • 6
  • Pedro Mota
    • 7
  • Juan Francisco Oteo
    • 8
  • Pilar Tornos
    • 3
  • David García-Dorado
    • 3
  1. 1.Cardiovascular Clinical Epidemiology Unit, Cardiology DepartmentUniversity Hospital Vall d’Hebron, Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP)BarcelonaSpain
  2. 2.Department of BusinessUniversitat Autònoma de BarcelonaBarcelonaSpain
  3. 3.Cardiology Department (CIBERCV)University Hospital Vall d’HebronBarcelonaSpain
  4. 4.Cardiology Department, Thorax Institute, Hospital Clinic, IDIBAPSUniversity of BarcelonaBarcelonaSpain
  5. 5.Cardiology Department, Departamento de Medicina, Instituto de Investigación Sanitaria Gregorio MarañónUniversidad ComplutenseMadridSpain
  6. 6.Unidad de Hemodinamica y Cardiología Intervencionista, Area del CorazónHospital Universitario Central de AsturiasOviedoSpain
  7. 7.Servicio de Cardiología, ICICORHospital Clínico UniversitarioValladolidSpain
  8. 8.Servicio de CardiologíaHospital Puerta de HierroMadridSpain

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