Transcatheter Aortic Valve Therapy in Northwestern Switzerland: Implications of a Landscape Change in Cardiovascular Treatment

Transcription

1 Transcatheter Aortic Valve Therapy in Northwestern Switzerland: Implications of a Landscape Change in Cardiovascular Treatment Master Thesis From the University of Applied Sciences and Arts Northwestern Switzerland School of Business Prof. Dr. med. Raban Jeger Cardiology University Hospital Basel

2 Table of Contents Aortic stenosis and its epidemiology: The scope of the problem Current treatment options: Surgical aortic valve replacement (SAVR) vs. transcatheter aortic valve implantation (TAVI) Expected changes in epidemiology and therapy: A possible scenario Economic consequences: Treatment at what cost?

3 Life Expectancy at Birth (World) United Nations Department of Economic and Social Affairs Population Division. World Population Ageing 2013.

4 Yearly Increase Population >65 Years (Switzerland) Eidgenössisches Departement des Innern EDI Bundesamt fu r Statistik BFS. BFS aktuell 1, Bevölkerung. Szenarien zur Bevölkerungsentwicklung der Schweiz

5 Valvular Heart Disease: Age and Prevalence Nkomo VT, et al. Lancet. 2006;368:

6 TAVI vs. SAVR in Intermediate- to High-Risk Patients (CoreValve U.S. Pivotal Trial) Adams DH et al, N Engl J Med 2014;370:1790-8

7 Cost-effectiveness of TAVI vs. SAVR in Patients With Severe Aortic Stenosis at High Operative Risk Hospital admission costs Cost-effectiveness plane Fairbairn TA et al. Heart 2013 Jul;99(13):914-20

8 Aortic Stenosis: Incidence Switzerland Source: Swiss Federal Bureau of Statistics Patients admitted to Swiss hospitals due to a diagnosis of aortic stenosis.

9 Aortic Valve Replacement (Switzerland) All Age Groups >70 Years Source: Swiss Federal Bureau of Statistics

10 Aortic Valve Replacement (Northwestern Switzerland) All Age Groups Similar trends in Northwestern Switzerland as in total Switzerland TAVI incidence of aortic valve therapies higher in Northwestern Switzerland than in the rest of the country (0.198 vs cases per thousand) Currently, the University Hospital Basel performs 8% of all SAVR and 18% of all TAVIs in Switzerland (Population NWCH 8% of CH) Source: University Hospital Basel

11 Summary: Epidemiology and Treatment of Aortic Stenosis Concomitant to the increase and the ageing of the population, incidence and prevalence of aortic stenosis increase as well While SAVR still is the gold standard in the treatment of aortic stenosis, TAVI offers distinct advances due to a less invasive approach In elderly or high-risk populations, TAVI has become the treatment of choice While numbers of TAVI increase, numbers of total SAVR remain constant and the number of mechanical SAVR decrease

12 Projected Frequencies of Aortic Valve Treatment Modalities (Switzerland, , All Age Groups)

13 Projected Frequencies of Aortic Valve Treatment Modalities (Switzerland, , All Age Groups) CAVE Competing technical advances of other techniques Limited pool of potential patients may be desiccated by current high TAVI numbers

14 Summary: Expected Changes in Aortic Valve Treatment Within the next decades, TAVI might replace SAVR as the standard treatment of aortic stenosis If the technical issues with TAVI can be solved, there will remain only some distinct subsets of patients being selected for SAVR Younger patients with a long lifespan Patients with concomitant severe coronary artery disease undergoing coronary artery bypass graft surgery Patients with anatomical variants However, the increase in TAVI numbers may be blunted due to competing technical advances of other techniques and a limited pool of potential patients

15 Swiss DRG for Transfemoral TAVI

16 DRG Reimbursement for Transfemoral TAVI (USB )

17 Costs for Transfemoral TAVI (USB )

18 Profit for Transfemoral TAVI (USB )

19 Cost Types for Transfemoral TAVI (USB 2015) Fixed Costs (Overhead) Variable Costs (Proportion)

20 Main Costs Drivers for Transfemoral TAVI (USB )

21 Main Costs Drivers for Transfemoral TAVI (USB ) Total %

22 Summary: Economy of Transfemoral TAVI The Swiss DRG system was introduced in 2012, and aimed at decreasing costs by improving transparency, efficacy, and quality From , reimbursement decreased but total costs remained stable; therefore, profit decreased to almost zero Fixed costs encompass for approx. 15% of total costs Within variable costs, device prices and personnel costs were the main cost drivers (approx. 80% of overall costs)

23 Strategies to Reduce Costs Reduction of material costs Negotiating lower device prices Reduction of cost-intensive complications Prevention of pacemaker implantations Thorough analysis of the anatomy and careful selection of patients Experienced team with a high caseload Increase of procedure efficacy Creation of optimal standard operational procedures Restrict the intervention to the TAVI procedure Use the minimum of material and personnel necessary Optimize patient management

24 Market Situations Supply > Demand Demand > Supply

25 Economies of Scale Costs per unit of output are lower with a higher scale because fixed costs are spread out over more units of output Operational efficiency greater with increasing scale, leading to lower variable costs Average Cost of Unit (long-run average cost curve) Quantity of Production

26 Cost-quality Curve «Flat-of-the-curve» («Quality») «Sweet spot» («Costs») Fuchs, V. R. (2004) Health Aff (Millwood), Suppl Variation, VAR104-7

27 Cost-quality Curve «Flat-of-the-curve» («Quality») «Sweet spot» Interventions in Medicine («Costs») Fuchs, V. R. (2004) Health Aff (Millwood), Suppl Variation, VAR104-7

28 Cost-quality Curve «Flat-of-the-curve» («Quality») «Sweet spot» Interventions in Medicine? («Costs») Fuchs, V. R. (2004) Health Aff (Millwood), Suppl Variation, VAR104-7

29 Conclusion and Perspective According to economic principles (buyer s market, economy of scale), large intervention numbers may lead to a decrease of costs (lower device prizes, optimization of workflow) Device prices encompass the largest percentage of total costs and are subject to cost savings; change to other devices do not necessarily have an effect on quality if devices of similar quality are selected A high quality must be maintained since the prevention of complications has a favorable effect on costs; however, the level of quality to achieve may be debatable Instead of expensive in-hospital resources, patient-tailored facilities such as step-down units, rehab hospitals, or even out-patient care could be used early after TAVI

30 Vielen Dank für Ihre Aufmerksamkeit