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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

Abstract

Objectives

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.

Methods

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.

Results

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.

Conclusions

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.

Keywords

Waiting lists Cost-utility Transcatheter aortic valve replacement Aortic stenosis 

JEL Classification

I Health, Education, and Welfare I1 Health I19 Other 

Notes

Acknowledgements

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.

Funding

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)

References

  1. 1.
    Morgan, D., Astoli, R.: Health spending growth at zero: whichcountries, which sectors are most affected?, OECD Health Working Papers, No. 60, OECD Publishing, Paris (2013).  http://dx.doi.org/10.1787/5k4dd1st95xv-en
  2. 2.
    Siciliani, L., Moran, V., Michael, Borowitz: Measuring and comparing health care waiting times in OECD countries. Health Policy (New York) 118, 292–303 (2014)CrossRefGoogle Scholar
  3. 3.
  4. 4.
    Eveborn, G.W., Schirmer, H., Heggelund, G., Lunde, P., Rasmussen, K.: The evolving epidemiology of valvular aortic stenosis. The Tromsø Study. Heart 99, 396–400 (2013)CrossRefPubMedGoogle Scholar
  5. 5.
    Lindroos, M., Kupari, M., Heikkilä, J., Tilvis, R.: Prevalence of aortic valve abnormalities in the elderly: an echocardiographic study of a random population sample. J. Am. Coll. Cardiol. 21, 1220–1225 (1993)CrossRefPubMedGoogle Scholar
  6. 6.
    Nkomo, V.T., Gardin, J.M., Skelton, T.N., Gottdiener, J.S., Scott, C.G., Enriquez-Sarano, M.: Burden of valvular heart diseases: a population-based study. Lancet 368, 1005–1011 (2006)CrossRefPubMedGoogle Scholar
  7. 7.
    Ferreira-González, I., Pinar-Sopena, J., Ribera, A., Marsal, J.R., Cascant, P., González-Alujas, T., Evangelista, A., Brotons, C., Moral, I., Permanyer-Miralda, G., García-Dorado, D., Tornos, P.: Prevalence of calcific aortic valve disease in the elderly and associated risk factors: a population-based study in a Mediterranean area. Eur. J. Prev. Cardiol. 20, 1022–1030 (2013)CrossRefPubMedGoogle Scholar
  8. 8.
    Rosenhek, R., Zilberszac, R., Schemper, M., Czerny, M., Mundigler, G., Graf, S., Bergler-Klein, J., Grimm, M., Gabriel, H., Maurer, G.: Natural history of very severe aortic stenosis. Circulation 121, 151–156 (2010)CrossRefPubMedGoogle Scholar
  9. 9.
    Ribera, A., Slof, J., Andrea, R., Falces, C., Gutiérrez, E., Del Valle-Fernández, R., Morís-De La Tassa, C., Mota, P., Oteo, J.F., Cascant, P., Altisent, O.A.J., Sureda, C., Serra, V., García-Del Blanco, B., Tornos, P., Garcia-Dorado, D., Ferreira-González, I.: Transfemoral transcatheter aortic valve replacement compared with surgical replacement in patients with severe aortic stenosis and comparable risk: cost-utility and its determinants. Int. J. Cardiol. 182, 321–328 (2015)CrossRefPubMedGoogle Scholar
  10. 10.
    Indraratna, P., Ang, S.C., Gada, H., Yan, T.D., Manganas, C., Bannon, P., Cao, C.: Systematic review of the cost-effectiveness of transcatheter aortic valve implantation. J. Thorac. Cardiovasc. Surg. 148, 509–514 (2014)CrossRefPubMedGoogle Scholar
  11. 11.
    Mylotte, D., Osnabrugge, R.L.J., Windecker, S., Lefèvre, T., de Jaegere, P., Jeger, R., Wenaweser, P., Maisano, F., Moat, N., Søndergaard, L., Bosmans, J., Teles, R.C., Martucci, G., Manoharan, G., Garcia, E., Van Mieghem, N.M., Kappetein, A.P., Serruys, P.W., Lange, R., Piazza, N.: Transcatheter aortic valve replacement in Europe: adoption trends and factors influencing device utilization. J. Am. Coll. Cardiol. 62, 210–219 (2013)CrossRefPubMedGoogle Scholar
  12. 12.
    Jiménez-Quevedo, P., Serrador, A., Pérez de Prado, A., Pan, M.: Registro Español de Hemodinámica y Cardiología Intervencionista. XXV Informe Oficial de la Sección de Hemodinámica y Cardiología Intervencionista de la Sociedad Española de Cardiología (1990–2015). Rev. Española Cardiol. 69, 1180–1189 (2016)CrossRefGoogle Scholar
  13. 13.
    Salinas, P., Moreno, R., Calvo, L., Sánchez-Recalde, Á., Jiménez-Valero, S., Galeote, G., López-Fernández, T., Ramírez, U., Riera, L., Plaza, I., Moreno, I., Mesa, J.M., López-Sendón, J.L.: Long-term follow-up after transcatheter aortic valve implantation for severe aortic stenosis. Rev. Española Cardiol. 69, 37–44 (2016)CrossRefGoogle Scholar
  14. 14.
    Avanzas, P., Pascual, I., Muñoz-García, A.J., Segura, J., Alonso-Briales, J.H., Suárez de Lezo, J., Pan, M., Jiménez-Navarro, M.F., López-Aguilera, J., Hernández-García, J.M., Morís, C.: Long-term follow-up of patients with severe aortic stenosis treated with a self-expanding prosthesis. Rev. Española Cardiol. 70, 247–253 (2016)CrossRefGoogle Scholar
  15. 15.
    Osnabrugge, R.L.J., Mylotte, D., Head, S.J., Van Mieghem, N.M., Nkomo, V.T., Lereun, C.M., Bogers, A.J.J.C., Piazza, N., Kappetein, P.: Aortic stenosis in the elderly: disease prevalence and number of candidates for transcatheter aortic valve replacement: a meta-analysis and modeling study. J. Am. Coll. Cardiol. 62, 1002–1012 (2013)CrossRefPubMedGoogle Scholar
  16. 16.
    Baumgartner, H., Falk, V., Bax, J.J., De Bonis, M., Hamm, C., Holm, P.J., Iung, B., Lancellotti, P., Lansac, E., Muñoz, D.R., Rosenhek, R., Sjögren, J., Tornos Mas, P., Vahanian, A., Walther, T., Wendler, O., Windecker, S., Zamorano, J.L.: 2017 ESC/EACTS guidelines for the management of valvular heart disease. Eur. Heart J. 38, 2739–2791 (2017)CrossRefPubMedGoogle Scholar
  17. 17.
    Leon, M.B., Smith, C.R., Mack, M.J., Makkar, R.R., Svensson, L.G., Kodali, S.K., Thourani, V.H., Tuzcu, E.M., Miller, D.C., Herrmann, H.C., Doshi, D., Cohen, D.J., Pichard, A.D., Kapadia, S., Dewey, T., Babaliaros, V., Szeto, W.Y., Williams, M.R., Kereiakes, D., Zajarias, A., Greason, K.L., Whisenant, B.K., Hodson, R.W., Moses, J.W., Trento, A., Brown, D.L., Fearon, W.F., Pibarot, P., Hahn, R.T., Jaber, W.A., Anderson, W.N., Alu, M.C., Webb, J.G.: PARTNER 2 investigators: transcatheter or surgical aortic-valve replacement in intermediate-risk patients. N. Engl. J. Med. 374, 1609–1620 (2016)CrossRefPubMedGoogle Scholar
  18. 18.
    Reardon, M.J., Van Mieghem, N.M., Popma, J.J., Kleiman, N.S., Søndergaard, L., Mumtaz, M., Adams, D.H., Deeb, G.M., Maini, B., Gada, H., Chetcuti, S., Gleason, T., Heiser, J., Lange, R., Merhi, W., Oh, J.K., Olsen, P.S., Piazza, N., Williams, M., Windecker, S., Yakubov, S.J., Grube, E., Makkar, R., Lee, J.S., Conte, J., Vang, E., Nguyen, H., Chang, Y., Mugglin, A.S., Serruys, P.W.J.C., Kappetein, A.P.: SURTAVI investigators: surgical or transcatheter aortic-valve replacement in intermediate-risk patients. N. Engl. J. Med. 376, 1321–1331 (2017)CrossRefPubMedGoogle Scholar
  19. 19.
    Vahanian, A., Alfieri, O., Andreotti, F., Antunes, M.J., Barón-Esquivias, G., Baumgartner, H., Borger, M.A., Carrel, T.P., De Bonis, M., Evangelista, A., Falk, V., Lung, B., Lancellotti, P., Pierard, L., Price, S., Schäfers, H.-J., Schuler, G., Stepinska, J., Swedberg, K., Takkenberg, J., Von Oppell, U.O., Windecker, S., Zamorano, J.L., Zembala, M.: Guidelines on the management of valvular heart disease (version 2012): the Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Eur. J. Cardiothorac. Surg. 42, S1–S44 (2012)CrossRefPubMedGoogle Scholar
  20. 20.
    Ramos-Goni, J.M., Rivero-Arias, O.: eq5d: a command to calculate index values for the EQ-5D quality-of-life instrument. Stata J. 11, 120–125 (2011)Google Scholar
  21. 21.
    Ministerio de Sanidad, Servicios Sociales e Igualdad. Instituto Nacional de Estadística. Encuesta Nacional de Salud. España 2011/12. Ministerio de Sanidad, Servicios Sociales e Igualdad, Madrid, 2013. http://www.msssi.gob.es/estadEstudios/estadisticas/sisInfSanSNS/nivelSalud.htm. Accessed 21 Nov 2017
  22. 22.
    Briggs, A., Sculpher, M.: An introduction to Markov modelling for economic evaluation. Pharmacoeconomics 13, 397–409 (1998)CrossRefPubMedGoogle Scholar
  23. 23.
    Siciliani, L., Stanciole, A., Jacobs, R.: Do waiting times reduce hospital costs? J. Health Econ. 28, 771–780 (2009)CrossRefPubMedGoogle Scholar
  24. 24.
    Kahneman, D., Tversky, A.: Prospect theory: an analysis of decision under risk. Econometrica 47, 263–291 (1979)CrossRefGoogle Scholar
  25. 25.
    Vallejo-Torres, L., García-Lorenzo, B., Castilla, I., Valcárcel Nazco, C., García-Pérez, L., Linertová, R., Serrano-Aguilar, P.: Valor Monetario de un AVAC: Estimación empírica del coste de oportunidad en el Sistema Nacional de Salud, Ministerio de Sanidad, Servicios Sociales e Igualdad. Servicio de Evaluación del Servicio Canario de la Salud; 2015. Informes de Evaluación de Tecnologías Sanitarias. http://www3.gobiernodecanarias.org/sanidad/scs/contenidoGenerico.jsp?idDocument=e690e0c1-cbed-11e5-a9c5-a398589805dc&idCarpeta=993a9b1d-7aed-11e4-a62a-758e414b4260. Accessed 21 Nov 2017
  26. 26.
    Henriksson, M., Palmer, S., Chen, R., Damant, J., Fitzpatrick, N.K., Abrams, K., Hingorani, A.D., Stenestrand, U., Janzon, M., Feder, G., Keogh, B., Shipley, M.J., Kaski, J.-C., Timmis, A., Sculpher, M., Hemingway, H.: Assessing the cost effectiveness of using prognostic biomarkers with decision models: case study in prioritising patients waiting for coronary artery surgery. BMJ 340, b5606 (2010)CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Watt, M., Mealing, S., Eaton, J., Piazza, N., Moat, N., Brasseur, P., Palmer, S., Busca, R., Sculpher, M.: Cost-effectiveness of transcatheter aortic valve replacement in patients ineligible for conventional aortic valve replacement. Heart 98, 370–376 (2012)CrossRefPubMedGoogle Scholar
  28. 28.
    Jahn, B., Pfeiffer, K.P., Theurl, E., Tarride, J.E., Goeree, R.: Capacity constraints and cost-effectiveness: a discrete event simulation for drug-eluting stents. Med. Decis. Making 30, 16–28 (2010)CrossRefPubMedGoogle Scholar
  29. 29.
    Comas, M., Castells, X., Hoffmeister, L., Román, R., Cots, F., Mar, J., Gutiérrez-Moreno, S., Espallargues, M.: Discrete-event simulation applied to analysis of waiting lists. Evaluation of a prioritization system for cataract surgery. Value Health 11, 1203–1213 (2008)CrossRefPubMedGoogle Scholar
  30. 30.
    Koopmanschap, M., Brouwer, W.B.F., Hakkaart-Van Roijen, L., Van Exel, N.J.: Influence of waiting time on cost-effectiveness. Soc. Sci. Med. 60, 2501–2504 (2005)CrossRefPubMedGoogle Scholar
  31. 31.
    Tuominen, U., Sintonen, H., Hirvonen, J., Seitsalo, S., Paavolainen, P., Lehto, M., Hietaniemi, K., Blom, M.: Is longer waiting time for total knee replacement associated with health outcomes and medication costs? Randomized clinical trial. Value Health 13, 998–1004 (2010)CrossRefPubMedGoogle Scholar
  32. 32.
    Tuominen, U., Sintonen, H., Aronen, P., Hirvonen, J., Seitsalo, S., Lehto, M., Hietaniemi, K., Blom, M.: Cost-utility of waiting time in total joint replacements: a randomized clinical trial. Int. J. Technol. Assess. Health Care 29, 27–34 (2013)CrossRefPubMedGoogle Scholar
  33. 33.
    Chauvin, P., Josselin, J.-M., Heresbach, D.: The influence of waiting times on cost-effectiveness: a case study of colorectal cancer mass screening. Eur. J. Health Econ. 15, 801–812 (2014)CrossRefPubMedGoogle Scholar

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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