Cost-utility analysis of sutureless and rapid deployment versus conventional aortic valve replacement in patients with moderate to severe aortic stenosis in Thailand.

BACKGROUND: Sutureless and rapid deployment aortic valve replacement (SUAVR) has become an alternative to conventional aortic valve replacement (CAVR) for aortic stenosis (AS) treatment due to its advantages in reducing surgery time and improving outcomes. This study aimed to assess the cost-utility of SUAVR vs. CAVR treatment for patients with moderate to severe AS in Thailand. METHODS: A two-part constructed model was used to estimate the lifetime costs and quality-adjusted life years (QALYs) from both societal and healthcare perspectives. Data on short-term mortality, complications, cost, and utility data were obtained from the Thai population. Long-term clinical data were derived from clinical studies. Costs and QALYs were discounted annually at 3% and presented as 2022 values. The incremental cost-effectiveness ratio (ICER) was calculated to determine additional cost per QALY gained. Deterministic and probabilistic sensitivity analyses were performed. RESULTS: SUAVR treatment incurred higher costs compared with CAVR treatment from both societal (THB 1,733,355 [USD 147,897] vs THB 1,220,643 [USD 104,150]) and healthcare provider perspectives (THB 1,594,174 [USD 136,022] vs THB 1,065,460 [USD 90,910]). In addition, SUAVR treatment resulted in lower health outcomes, with 6.20 life-years (LYs) and 4.95 QALYs, while CAVR treatment achieved 6.29 LYs and 5.08 QALYs. SUAVR treatment was considered as a dominated treatment strategy using both perspectives. Sensitivity analyses indicated the significant impact of changes in utilities and long-term mortality on the model. CONCLUSION: SUAVR treatment is not a cost-effective treatment strategy compared with CAVR treatment for patients with moderate-severe AS in Thailand, as it leads to higher costs and inferior health outcomes. Other important issues related to specific patients such as those with minimally invasive surgery, those undergoing AVR with concomitant procedures, and those with calcified and small aortic root should be taken into account.

Trends in Economic Burden and Mortality of Hospitalized Patients With Aortic Stenosis in Thailand.

This study aimed to assess the temporal trends in aortic stenosis (AS)-related hospitalizations, in-hospital mortality, and economic burden in Thailand. The study cohort was derived from the electronic claim system of the National Health Security Office, which serves as a reimbursement database for all Thai beneficiaries under the Universal Health Coverage Scheme, covering ∼70% of the entire population. Hospitalization, mortality, and costs were estimated by year, with the primary diagnosis for AS-related hospitalizations identified using code I350. The Cochrane Armitage test was used to examine trends in AS-related hospitalization and in-hospital mortality, whereas a nonparametric trend test was used to analyze the trend of hospitalization costs. Of the 8-year period, 10,406 adults were admitted with a primary diagnosis of AS. AS-related hospitalizations increased from 1,274 in 2015 to 1,945 in 2022 (p = 0.251), with the most significant observed in the age group 60 to 79 years (p <0.001). In-hospital mortality increased from 4.8% to 6.1%. Hospitalization cost significantly increased from $2,879 to $3,443 (p <0.001), with an average length of stay of 6.6 ± 9.2 days. The trend of patients admitted with primary diagnosis of AS in Thailand has significantly increased in the age group 60 to 79 years. In-hospital admission is found at older age and is likely to have high mortality rate. The increased hospitalization cost may impose a substantial economic burden on the Thai health care system.

Discounting money and health effects from communicable and noncommunicable diseases in Thailand.

The purpose of this study was to determine the discount rates for money and health outcomes in the Thai context, including the discount rates for communicable and non-communicable diseases. Moreover, this study aimed to explore the socio-demographic characteristics that influence discounting. The computer-based experimental design was used to obtain time preferences for money and health in a total of 1202 Chiang Mai province population, aged 25-50, individually interviewed by trained interviewers. Money-related questions were carried out in all subjects. For health-related questions, all subjects were randomly assigned in a 1:1 ratio for response to questions about Coronavirus Disease 2019 (COVID-19) (N = 602) and air pollution (N = 600). A choice-based elicitation procedure was performed in the experiment to obtain the indifference values from subjects' time preferences. The cumulative weighting functions were generated using the indifference values to indicate the degree of discounting. The discount factors were computed from the cumulative weighting functions. The discount rates were estimated using a continuous approximation based on the relationship between the discount factors and the parameters governing the discounting model. The Tobit model was applied to investigate the relationships between discounting and socio-demographic characteristics. Discounting for money was greater than discounting for health. Money and health had annual discount rates of 6.2% and 1.3%, respectively. Furthermore, in the COVID -19 situation, the annual discount rate for health was higher than that in the air pollution situation (2.4% vs. 0.7%). Generation X subjects (aged 42 years and above), children under the age of 15 in the household, and underlying diseases were positively related to discounting, while household income was negatively related to discounting. Health should be discounted at a lower rate than money. Moreover, different discount rates should be considered for different types of diseases.

Transcatheter aortic valve implantation in patients with severe symptomatic aortic valve stenosis: systematic review of cost-effectiveness analysis.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is a less invasive and costly treatment for patients with severe aortic stenosis (AS). This study aimed to systematically review the published literature focusing on economic evaluation of TAVI compared with other alternative treatments in AS populations. METHODS: A systematic review was conducted from inception until May 2021 using PubMed, Scopus, Web of science and Embase databases. The qualities of included studies were evaluated using Consolidated Health Economic Evaluation Reporting Standard (CHEERS) criteria. Data of costs, outcomes, incremental cost-effectiveness ratio (ICER) and willingness to pay were extracted. To compare results, ICERs were converted to the 2020 United States dollar (USD) rate. RESULTS: Of the 29 included cost-effectiveness studies, TAVI was cost-effective in all studies in the low-risk group (3/3), 77% of studies (7/9) in the intermediate-risk group, half of the studies (6/12) in the high-risk group, and 83% of studies (10/12) in the inoperable group. When adjusted to USD 2020, ICERs ranged from USD 2741 to 1027,674 USD per quality-adjusted life-year gained. The overall quality of the studies ranged from moderate to high. CONCLUSIONS: TAVI is potentially a cost-effective alternative to surgical aortic valve replacement (SAVR) for patients with operable AS with low, intermediate or high risk compared with medical management (MM) for patients with inoperable AS. TAVI was associated with a significant gain in quality-adjusted life-years in almost all studies compared to either SAVR or MM. TAVI is a costly procedure; therefore, justifying its cost-effectiveness depends on the acceptable threshold in each country.

Cost-utility analysis of transcatheter aortic valve implantation versus surgery in severe aortic stenosis patients with intermediate surgical risk in Thailand.

BACKGROUND: Transcatheter Aortic Valve Implantation (TAVI) has been shown to provide comparable survival benefit and improvement in quality of life to surgical aortic valve replacement (SAVR) for treating patients with severe aortic stenosis (AS) at intermediate surgical risk. This study aimed to evaluate the cost-utility of TAVI compared with SAVR for severe aortic stenosis with intermediate surgical risk in Thailand. METHODS: A two-part constructed model was used to analyze lifetime costs and quality-adjusted life-years (QALYs) from societal and healthcare perspectives. The study cohort comprised severe AS patients at intermediate surgical risk with an average age of 80 years. The landmark trials were used to populate the model in terms of mortality and adverse event rates. All cost-related data and quality of life were based on Thai population. Costs and QALYs were discounted at 3% annually and presented as 2021 values. Incremental cost-effectiveness ratios (ICERs) were calculated. Deterministic and probabilistic sensitivity analyses were conducted. RESULTS: In comparison to SAVR, TAVI resulted in higher total cost (THB 1,717,132 [USD 52,415.51] vs. THB 893,524 [USD 27,274.84]) and higher QALYs (4.88 vs. 3.98) in a societal perspective. The estimated ICER was THB 906,937/QALY (USD 27,684.27/QALY). From a healthcare system perspective, TAVI also had higher total cost than SAVR (THB 1,573,751 [USD 48,038.79] vs. THB 726,342 [USD 22,171.63]) with similar QALYs gained to the societal perspective. The estimated ICER was THB 933,145/QALY (USD 933,145/QALY). TAVI was not cost-effective at the Thai willingness to pay (WTP) threshold of THB 160,000/QALY (USD 4,884/QALY). The results were sensitive to utility of either SAVR or TAVI treatment and cost of TAVI valve. CONCLUSION: In patients with severe AS at intermediate surgical risk, TAVI is not a cost-effective strategy compared with SAVR at the WTP of THB 160,000/QALY (USD 4,884/QALY) from the perspectives of society and healthcare system.

Cost-Utility Analysis of Transcatheter Aortic Valve Implantation versus Surgery in High-Risk Severe Aortic Stenosis Patients in Thailand.

Background: Transcatheter aortic valve implantation (TAVI) has been shown to be effective in treating patients with severe symptomatic AS who are high-risk population for conventional surgical aortic valve replacement (SAVR). This study aimed to evaluate the cost-utility of TAVI compared with SAVR for severe aortic stenosis with high surgical risk in Thailand. Methods: Lifetime costs and quality-adjusted life years (QALYs) from societal and healthcare perspectives were estimated using a two-part constructed model. The study population consisted of 80-year-old severe AS patients with high surgical risk. Mortality and complication rates were obtained from landmark trials. All cost-related and utility data were based on Thai population. Costs and QALYs were discounted at a rate of 3% annually and presented as 2021 values. Incremental cost-effectiveness ratios (ICERs) were computed. Sensitivity analyses were performed both deterministically and probabilistically. Results: The findings from a societal perspective revealed that TAVI treatment was associated with higher cost (THB 1,551,895 [USD 47,371.64] vs THB 548,438 [USD 16,741.09] and higher QALYs than SAVR treatment (3.15 vs 2.31 QALYs). The estimated ICER was THB 1,196,191/QALY (USD 36,513.78 QALY). For the healthcare system perspective, TAVI treatment resulted in a higher total cost than SAVR treatment (THB 1,451,317 [USD 44,301.49] vs THB 432,398 [USD 13,198.95]) with comparable gains in LY and QALYs from a societal perspective. The ICER was calculated to be THB 1,214,624/QALY (USD 37,076.42/QALY). TAVI was not cost-effective at the Thai willingness to pay (WTP) threshold of THB 160,000/QALY (USD 4884/QALY). The model was the most sensitive to changes in TAVI valve cost and TAVI or SAVR treatment utilities. Conclusion: TAVI is not a cost-effective strategy in patients with severe AS who are at high surgical risk when compared to SAVR at the WTP of THB 160,000/QALY (USD 4884/QALY) from the perspectives of society and the healthcare system.

Cost-Effectiveness Analysis of the Adjunctive Therapy of Ivabradine for the Treatment of Heart Failure with Reduced Ejection Fraction.

BACKGROUND: The benefit of ivabradine as an adjunctive therapy to conventional treatment in patients with heart failure (HF) with reduced ejection fraction (HFrEF) is a reduction in both cardiovascular death and HF hospitalization. This study aimed to analyze the cost-effectiveness of ivabradine plus standard treatment compared with standard treatment alone. METHODS AND RESULTS: An analytical decision model was used to analyze lifetime costs and quality-adjusted life-years (QALYs) from a healthcare perspective. The study cohort comprised HFrEF patients with left ventricular ejection fraction (LVEF) <35%, with subgroup analysis of those with baseline heart rate ≥77 bpm. Clinical inputs were obtained from a landmark trial. All cost-related data, risk of non-cardiovascular death and readmission rate were based on Thai data. Costs and QALYs were discounted at 3% and presented as 2018 values. Findings were reported as incremental cost-effectiveness ratios (ICERs). Sensitivity analyses were also performed. Ivabradine plus standard treatment costs more than standard treatment (71,071 vs 18,736 THB or 2,161.54 vs 569.82 USD), and is more effective (6.08 QALYs vs 5.84 QALYs), yielding an ICER of 214,219 THB/QALY (6,515.16 USD/QALY). Ivabradine was not cost-effective at the Thai willingness to pay threshold of 160,000 THB/QALY. The results were sensitive to risk of non-hospitalization cardiovascular death, and costs of HF hospitalization and ivabradine. However, the ICER of subgroup was below the threshold (86,317 THB/QALY or 2,625.20 USD/QALY). CONCLUSION: This study revealed the addition of ivabradine to standard treatment to be a cost-effective treatment strategy in HFrEF patients with a heart rate ≥77 bpm.

Assessing evidence of interventions addressing inequity among migrant populations: a two-stage systematic review.

BACKGROUND: Everyone has the right to achieve the standard of health and well-being. Migrants are considered as vulnerable populations due to the lack of access to health services and financial protection in health. Several interventions have been developed to improve migrant population health, but little is known about whether these interventions have considered the issue of equity as part of their outcome measurement. OBJECTIVE: To assess the evidence of health interventions in addressing inequity among migrants. METHODS: We adopted a two-stage searching approach to ensure the feasibility of this review. First, reviews of interventions for migrants were searched from five databases: PubMed, Cochrane, CINAHL, PsycINFO, and EMBASE until June 2017. Second, full articles included in the identified reviews were retrieved. Primary studies included in the identified reviews were then evaluated as to whether they met the following criteria: experimental studies which include equity aspects as part of their outcome measurement, based on equity attributes defined by PROGRESS-Plus factors (place of residence, race/ethnicity, occupation, gender, religion, education, socio-economic status, social capital, and others). We analysed the information extracted from the selected articles based on the PRISMA-Equity guidelines and the PROGRESS-Plus factors. RESULTS: Forty-nine reviews involving 1145 primary studies met the first-stage inclusion criteria. After exclusion of 764 studies, the remaining 381 experimental studies were assessed. Thirteen out of 381 experimental studies (3.41%) were found to include equity attributes as part of their outcome measurement. However, although some associations were found none of the included studies demonstrated the effect of the intervention on reducing inequity. All studies were conducted in high-income countries. The interventions included individual directed, community education and peer navigator-related interventions. CONCLUSIONS: Current evidence reveals that there is a paucity of studies assessing equity attributes of health interventions developed for migrant populations. This indicates that equity has not been receiving attention in these studies of migrant populations. More attention to equity-focused outcome assessment is needed to help policy-makers to consider all relevant outcomes for sound decision making concerning migrants.