Cost-Effectiveness of Mitral Valve Repair Versus Replacement for Severe Ischemic Mitral Regurgitation: A Randomized Clinical Trial From the Cardiothoracic Surgical Trials Network

Bart S. Ferket, Gorav A. Ailawadi, Annetine C.G. Gelijns, Michael A.A. Acker, Samuel F. Hohmann, Helena L. Chang, Denis B. Bouchard,, David O. Meltzer, Robert E.M. Michler, Ellen G. Moquete, Pierre V. Voisine, John C.M. Mullen, Anuradha L. Lala, Michael J.M. Mack, A. Marc Gillinov, Vinod H. Thourani, Marissa A. Miller, James S.G. Gammie, Michael K.P. Parides, Emilia B. BagiellaRobert L.S. Smith, Peter K.S. Smith, Judy W.H. Hung, Lopa N.G. Gupta, Eric A.R. Rose, Patrick T.O. O'Gara, Alan J.M. Moskowitz, Surgical Trials Network (CTSN) Investigators Cardiothoracic Surgical Trials Network (CTSN) Investigators

Research output: Contribution to journalArticle

Abstract

BACKGROUND: The CTSN (Cardiothoracic Surgical Trials Network) recently reported no difference in left ventricular end-systolic volume index or in survival at 2 years between patients with severe ischemic mitral regurgitation (MR) randomized to mitral valve repair or replacement. However, replacement provided more durable correction of MR and fewer cardiovascular readmissions. Yet, costeffectiveness outcomes have not been addressed. METHODS AND RESULTS: We conducted a cost-effectiveness analysis of the surgical treatment of ischemic MR based on the CTSN trial (n=126 for repair; n=125 for replacement). Patient-level data on readmissions, survival, qualityof- life, and US hospital costs were used to estimate costs and quality-adjusted life years per patient over the trial duration and a 10-year time horizon. We performed microsimulation for extrapolation of outcomes beyond the 2 years of trial data. Bootstrap and deterministic sensitivity analyses were done to address parameter uncertainty. In-hospital cost estimates were $78 216 for replacement versus $72 761 for repair (difference: $5455; 95% uncertainty interval [UI]: −7784–21 193) while 2-year costs were $97 427 versus $96 261 (difference: $1166; 95% UI: −16 253–17 172), respectively. Quality-adjusted life years at 2 years were 1.18 for replacement versus 1.23 for repair (difference: −0.05; 95% UI: −0.17 to 0.07). Over 5 and 10 years, the benefits of reduction in cardiovascular readmission rates with replacement increased, and survival minimally improved compared with repair. At 5 years, cumulative costs and quality-adjusted life years showed no difference on average, but by 10 years, there was a small, uncertain benefit for replacement: $118 023 versus $119 837 (difference: −$1814; 95% UI: −27 144 to 22 602) and qualityadjusted life years: 4.06 versus 3.97 (difference: 0.09; 95% UI: −0.87 to 1.08). After 10 years, the incremental cost-effectiveness of replacement continued to improve. CONCLUSIONS: Our cost-effectiveness analysis predicts potential savings in cost and gains in quality-adjusted survival at 10 years when mitral valve replacement is compared with repair for severe ischemic MR. These projected benefits, however, were small and subject to variability. Efforts to further delineate predictors of long-term outcomes in patients with severe ischemic MR are needed to optimize surgical decisions for individual patients, which should yield more cost-effective care. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT00807040.

Original languageEnglish (US)
Number of pages1
JournalCirculation. Cardiovascular quality and outcomes
Volume11
Issue number11
DOIs
StatePublished - Nov 14 2018

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Mitral Valve Insufficiency
Mitral Valve
Uncertainty
Cost-Benefit Analysis
Randomized Controlled Trials
Quality-Adjusted Life Years
Costs and Cost Analysis
Survival
Hospital Costs
Cost Savings
Stroke Volume
Clinical Trials

Keywords

  • Cardiac surgical procedures
  • cost-benefit analysis
  • health care costs
  • mitral valve
  • quality-adjusted life years

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

Cite this

Ferket, B. S., Ailawadi, G. A., Gelijns, A. C. G., Acker, M. A. A., Hohmann, S. F., Chang, H. L., ... Cardiothoracic Surgical Trials Network (CTSN) Investigators, S. T. N. CTSN. I. (2018). Cost-Effectiveness of Mitral Valve Repair Versus Replacement for Severe Ischemic Mitral Regurgitation: A Randomized Clinical Trial From the Cardiothoracic Surgical Trials Network. Circulation. Cardiovascular quality and outcomes, 11(11). https://doi.org/10.1161/CIRCOUTCOMES.117.004466

Cost-Effectiveness of Mitral Valve Repair Versus Replacement for Severe Ischemic Mitral Regurgitation : A Randomized Clinical Trial From the Cardiothoracic Surgical Trials Network. / Ferket, Bart S.; Ailawadi, Gorav A.; Gelijns, Annetine C.G.; Acker, Michael A.A.; Hohmann, Samuel F.; Chang, Helena L.; Bouchard, Denis B.; Meltzer, David O.; Michler, Robert E.M.; Moquete, Ellen G.; Voisine, Pierre V.; Mullen, John C.M.; Lala, Anuradha L.; Mack, Michael J.M.; Gillinov, A. Marc; Thourani, Vinod H.; Miller, Marissa A.; Gammie, James S.G.; Parides, Michael K.P.; Bagiella, Emilia B.; Smith, Robert L.S.; Smith, Peter K.S.; Hung, Judy W.H.; Gupta, Lopa N.G.; Rose, Eric A.R.; O'Gara, Patrick T.O.; Moskowitz, Alan J.M.; Cardiothoracic Surgical Trials Network (CTSN) Investigators, Surgical Trials Network (CTSN) Investigators.

In: Circulation. Cardiovascular quality and outcomes, Vol. 11, No. 11, 14.11.2018.

Research output: Contribution to journalArticle

Ferket, BS, Ailawadi, GA, Gelijns, ACG, Acker, MAA, Hohmann, SF, Chang, HL, Bouchard, DB, Meltzer, DO, Michler, REM, Moquete, EG, Voisine, PV, Mullen, JCM, Lala, AL, Mack, MJM, Gillinov, AM, Thourani, VH, Miller, MA, Gammie, JSG, Parides, MKP, Bagiella, EB, Smith, RLS, Smith, PKS, Hung, JWH, Gupta, LNG, Rose, EAR, O'Gara, PTO, Moskowitz, AJM & Cardiothoracic Surgical Trials Network (CTSN) Investigators, STNCTSNI 2018, 'Cost-Effectiveness of Mitral Valve Repair Versus Replacement for Severe Ischemic Mitral Regurgitation: A Randomized Clinical Trial From the Cardiothoracic Surgical Trials Network', Circulation. Cardiovascular quality and outcomes, vol. 11, no. 11. https://doi.org/10.1161/CIRCOUTCOMES.117.004466
Ferket, Bart S. ; Ailawadi, Gorav A. ; Gelijns, Annetine C.G. ; Acker, Michael A.A. ; Hohmann, Samuel F. ; Chang, Helena L. ; Bouchard, Denis B. ; Meltzer, David O. ; Michler, Robert E.M. ; Moquete, Ellen G. ; Voisine, Pierre V. ; Mullen, John C.M. ; Lala, Anuradha L. ; Mack, Michael J.M. ; Gillinov, A. Marc ; Thourani, Vinod H. ; Miller, Marissa A. ; Gammie, James S.G. ; Parides, Michael K.P. ; Bagiella, Emilia B. ; Smith, Robert L.S. ; Smith, Peter K.S. ; Hung, Judy W.H. ; Gupta, Lopa N.G. ; Rose, Eric A.R. ; O'Gara, Patrick T.O. ; Moskowitz, Alan J.M. ; Cardiothoracic Surgical Trials Network (CTSN) Investigators, Surgical Trials Network (CTSN) Investigators. / Cost-Effectiveness of Mitral Valve Repair Versus Replacement for Severe Ischemic Mitral Regurgitation : A Randomized Clinical Trial From the Cardiothoracic Surgical Trials Network. In: Circulation. Cardiovascular quality and outcomes. 2018 ; Vol. 11, No. 11.
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abstract = "BACKGROUND: The CTSN (Cardiothoracic Surgical Trials Network) recently reported no difference in left ventricular end-systolic volume index or in survival at 2 years between patients with severe ischemic mitral regurgitation (MR) randomized to mitral valve repair or replacement. However, replacement provided more durable correction of MR and fewer cardiovascular readmissions. Yet, costeffectiveness outcomes have not been addressed. METHODS AND RESULTS: We conducted a cost-effectiveness analysis of the surgical treatment of ischemic MR based on the CTSN trial (n=126 for repair; n=125 for replacement). Patient-level data on readmissions, survival, qualityof- life, and US hospital costs were used to estimate costs and quality-adjusted life years per patient over the trial duration and a 10-year time horizon. We performed microsimulation for extrapolation of outcomes beyond the 2 years of trial data. Bootstrap and deterministic sensitivity analyses were done to address parameter uncertainty. In-hospital cost estimates were $78 216 for replacement versus $72 761 for repair (difference: $5455; 95{\%} uncertainty interval [UI]: −7784–21 193) while 2-year costs were $97 427 versus $96 261 (difference: $1166; 95{\%} UI: −16 253–17 172), respectively. Quality-adjusted life years at 2 years were 1.18 for replacement versus 1.23 for repair (difference: −0.05; 95{\%} UI: −0.17 to 0.07). Over 5 and 10 years, the benefits of reduction in cardiovascular readmission rates with replacement increased, and survival minimally improved compared with repair. At 5 years, cumulative costs and quality-adjusted life years showed no difference on average, but by 10 years, there was a small, uncertain benefit for replacement: $118 023 versus $119 837 (difference: −$1814; 95{\%} UI: −27 144 to 22 602) and qualityadjusted life years: 4.06 versus 3.97 (difference: 0.09; 95{\%} UI: −0.87 to 1.08). After 10 years, the incremental cost-effectiveness of replacement continued to improve. CONCLUSIONS: Our cost-effectiveness analysis predicts potential savings in cost and gains in quality-adjusted survival at 10 years when mitral valve replacement is compared with repair for severe ischemic MR. These projected benefits, however, were small and subject to variability. Efforts to further delineate predictors of long-term outcomes in patients with severe ischemic MR are needed to optimize surgical decisions for individual patients, which should yield more cost-effective care. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT00807040.",
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TY - JOUR

T1 - Cost-Effectiveness of Mitral Valve Repair Versus Replacement for Severe Ischemic Mitral Regurgitation

T2 - A Randomized Clinical Trial From the Cardiothoracic Surgical Trials Network

AU - Ferket, Bart S.

AU - Ailawadi, Gorav A.

AU - Gelijns, Annetine C.G.

AU - Acker, Michael A.A.

AU - Hohmann, Samuel F.

AU - Chang, Helena L.

AU - Bouchard,, Denis B.

AU - Meltzer, David O.

AU - Michler, Robert E.M.

AU - Moquete, Ellen G.

AU - Voisine, Pierre V.

AU - Mullen, John C.M.

AU - Lala, Anuradha L.

AU - Mack, Michael J.M.

AU - Gillinov, A. Marc

AU - Thourani, Vinod H.

AU - Miller, Marissa A.

AU - Gammie, James S.G.

AU - Parides, Michael K.P.

AU - Bagiella, Emilia B.

AU - Smith, Robert L.S.

AU - Smith, Peter K.S.

AU - Hung, Judy W.H.

AU - Gupta, Lopa N.G.

AU - Rose, Eric A.R.

AU - O'Gara, Patrick T.O.

AU - Moskowitz, Alan J.M.

AU - Cardiothoracic Surgical Trials Network (CTSN) Investigators, Surgical Trials Network (CTSN) Investigators

PY - 2018/11/14

Y1 - 2018/11/14

N2 - BACKGROUND: The CTSN (Cardiothoracic Surgical Trials Network) recently reported no difference in left ventricular end-systolic volume index or in survival at 2 years between patients with severe ischemic mitral regurgitation (MR) randomized to mitral valve repair or replacement. However, replacement provided more durable correction of MR and fewer cardiovascular readmissions. Yet, costeffectiveness outcomes have not been addressed. METHODS AND RESULTS: We conducted a cost-effectiveness analysis of the surgical treatment of ischemic MR based on the CTSN trial (n=126 for repair; n=125 for replacement). Patient-level data on readmissions, survival, qualityof- life, and US hospital costs were used to estimate costs and quality-adjusted life years per patient over the trial duration and a 10-year time horizon. We performed microsimulation for extrapolation of outcomes beyond the 2 years of trial data. Bootstrap and deterministic sensitivity analyses were done to address parameter uncertainty. In-hospital cost estimates were $78 216 for replacement versus $72 761 for repair (difference: $5455; 95% uncertainty interval [UI]: −7784–21 193) while 2-year costs were $97 427 versus $96 261 (difference: $1166; 95% UI: −16 253–17 172), respectively. Quality-adjusted life years at 2 years were 1.18 for replacement versus 1.23 for repair (difference: −0.05; 95% UI: −0.17 to 0.07). Over 5 and 10 years, the benefits of reduction in cardiovascular readmission rates with replacement increased, and survival minimally improved compared with repair. At 5 years, cumulative costs and quality-adjusted life years showed no difference on average, but by 10 years, there was a small, uncertain benefit for replacement: $118 023 versus $119 837 (difference: −$1814; 95% UI: −27 144 to 22 602) and qualityadjusted life years: 4.06 versus 3.97 (difference: 0.09; 95% UI: −0.87 to 1.08). After 10 years, the incremental cost-effectiveness of replacement continued to improve. CONCLUSIONS: Our cost-effectiveness analysis predicts potential savings in cost and gains in quality-adjusted survival at 10 years when mitral valve replacement is compared with repair for severe ischemic MR. These projected benefits, however, were small and subject to variability. Efforts to further delineate predictors of long-term outcomes in patients with severe ischemic MR are needed to optimize surgical decisions for individual patients, which should yield more cost-effective care. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT00807040.

AB - BACKGROUND: The CTSN (Cardiothoracic Surgical Trials Network) recently reported no difference in left ventricular end-systolic volume index or in survival at 2 years between patients with severe ischemic mitral regurgitation (MR) randomized to mitral valve repair or replacement. However, replacement provided more durable correction of MR and fewer cardiovascular readmissions. Yet, costeffectiveness outcomes have not been addressed. METHODS AND RESULTS: We conducted a cost-effectiveness analysis of the surgical treatment of ischemic MR based on the CTSN trial (n=126 for repair; n=125 for replacement). Patient-level data on readmissions, survival, qualityof- life, and US hospital costs were used to estimate costs and quality-adjusted life years per patient over the trial duration and a 10-year time horizon. We performed microsimulation for extrapolation of outcomes beyond the 2 years of trial data. Bootstrap and deterministic sensitivity analyses were done to address parameter uncertainty. In-hospital cost estimates were $78 216 for replacement versus $72 761 for repair (difference: $5455; 95% uncertainty interval [UI]: −7784–21 193) while 2-year costs were $97 427 versus $96 261 (difference: $1166; 95% UI: −16 253–17 172), respectively. Quality-adjusted life years at 2 years were 1.18 for replacement versus 1.23 for repair (difference: −0.05; 95% UI: −0.17 to 0.07). Over 5 and 10 years, the benefits of reduction in cardiovascular readmission rates with replacement increased, and survival minimally improved compared with repair. At 5 years, cumulative costs and quality-adjusted life years showed no difference on average, but by 10 years, there was a small, uncertain benefit for replacement: $118 023 versus $119 837 (difference: −$1814; 95% UI: −27 144 to 22 602) and qualityadjusted life years: 4.06 versus 3.97 (difference: 0.09; 95% UI: −0.87 to 1.08). After 10 years, the incremental cost-effectiveness of replacement continued to improve. CONCLUSIONS: Our cost-effectiveness analysis predicts potential savings in cost and gains in quality-adjusted survival at 10 years when mitral valve replacement is compared with repair for severe ischemic MR. These projected benefits, however, were small and subject to variability. Efforts to further delineate predictors of long-term outcomes in patients with severe ischemic MR are needed to optimize surgical decisions for individual patients, which should yield more cost-effective care. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT00807040.

KW - Cardiac surgical procedures

KW - cost-benefit analysis

KW - health care costs

KW - mitral valve

KW - quality-adjusted life years

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