Predictors of Cumulative Health Care Costs Associated With Transcatheter Aortic Valve Replacement in Severe Aortic Stenosis

Abstract

Background: There is wide variation in hospitalization costs for transcatheter aortic valve replacement (TAVR), suggesting inefficiency in care delivery. Our goal was to identify drivers of health care costs in TAVR.

Methods: Demographics, procedural details, in-hospital complications, and costs for all adults undergoing first-time TAVR from 2012 to 2016 in Ontario, Canada, were obtained through linkages of clinical/administrative databases. Total costs included were from initial referral to the first of either death or 1-year post-TAVR. Phase-based costing was performed to empirically estimate the presence, duration, and cost per patient for each phase up to 1 year or death. Multivariable regression was used to identify drivers of cost accumulation per phase.

Results: We identified 2009 first-time TAVR patients (mean age 81.7 ± 7.6, 45.9% female and Society of Thoracic Surgeons (STS) score of 7.2 ± 5.8). Phases of cost were identified with an early high-cost period within 60 days of referral, a second phase from the procedure to 60 days, and a stable phase from 60 to 360 days postprocedure. The referral phase median cost was $4527 (interquartile range [IQR]: 1708-12,594), the procedure to 60 days phase median cost was $29,518 (IQR: 24,842-40,279), and the post 60-day stable phase median cost was $6053 (IQR: 3320-17,048). Predictors of higher cost in the referral phase were in-hospital wait location, dialysis dependence, and heart-failure status. In the second (procedural) phase, predictors were nontransfemoral access, complications of stroke, and pacemaker insertion. Predictors of higher cost in the third (stable) phase were predominantly nonmodifiable, such as frailty.

Conclusions: This analysis shows that there are 3 distinct phases of cost accumulation from referral to post-TAVR with some potentially modifiable cost drivers in each phase.