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The recommendation is that TAVI and sutureless AVR procedures are provided within the existing cardiac surgical budget. The expected additional cost to DHBs of providing TAVI to technically inoperable patients is about $1 million per annum, increasing to $1.7 million by 2019/20. Sutureless AVR costs are estimated to be only slightly ($2,000) more expensive than surgical AVR, with this gap reducing over time as the cost of the valve reduces.
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The economic assessments for sutureless AVR and TAVI have been based on international evidence and the New Zealand data that is available through the national costing programme. These costs have also been checked with Auckland DHB. It is recognised that there are limitations with small datasets and applying the assumptions locally from international studies, however, we believe the costs presented in the Tier 3 assessments for the delivery of both TAVI and sutureless AVR impartially represent available information.
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Further input from stakeholders relating to implementation is required to fully understand the system-wide costs of the other aspects of the revised model of care. These costs include the costs of the national registry, change to surgical risk assessment, implementation of a frailty tool, the potential addition of two years of follow-up, the addition of a quality of life measurement tool, data collection, entry and reporting, and any further costs associated with the multidisciplinary team, eg costs of geriatrician time.
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Further analysis is also required to cost the benefit of the new model of care, ie what is the overall saving from introducing the four decision-making points and national registry? While there may be a willingness to reprioritise within the cardiac surgery budget to accommodate sutureless AVR and TAVI, the sector will want to understand the financial and other benefits of investing in better data collection (national registry) and the inclusion of geriatricians in the multidisciplinary clinical teams.
Implementation -
There remain a number of complex issues and challenges to consider for implementation. Feedback from the sector is required to better understand how these may be managed. Some of these challenges include:
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Refocusing TAVI delivery on high-risk and technically inoperable patients.
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Applying an appropriate intervention rate for each DHB’s population for AS interventions (surgical AVR, sutureless AVR, TAVI, medical management).
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Managing the diffusion of TAVI in the longer term. TAVI is likely to become more widely used as evidence of its relative safety, effectiveness and cost-effectiveness in lower risk populations becomes available.
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Management of unmet need identified through improved referral pathways from primary care through to cardiology.
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Access to diagnostics in a timely way to inform each decision point in the model of care.
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Managing existing workforce issues within these services while implementing a revised model of care. There are existing workforce vacancies for perfusionists and sonographers. A significant medium-term workforce issue relating to the replacement of cardiothoracic surgeons as the current group retires and an issue relating to the scope of practice and facilities available to encourage cardiologists to be based in provincial centres.
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The scope of practice between cardiologists and cardiac surgeons is blurring as TAVI procedures are provided by both specialties in NZ, the implications of which need to be carefully managed.
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Establishing a fair and transparent national price for TAVI and for other AS interventions which reflect the costs of delivering AS interventions for both the DHB of domicile and the DHB of service. Recognising that in 2013/14 the DRGs related to AVR showed a shortfall. While this can create an incentive to prioritise these interventions locally and only fund the procedure when it makes sense – ie not in low-risk patients, this may be challenging in reality.
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Establishing a national registry for the AS model of care when there are two established registries in the sector which could be used to house the AS registry.
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Establishing a nationally consistent approach to clinical decision-making when regional cardiac centres and TAVI centres have developed based on what works locally/regionally.
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Maximising the opportunity of national purchasing and procurement for aortic valves. For example, one type of sutureless valve may be twice the price of its competitor, with no head-to-head trial evidence justifying the price differential.
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Managing facility capacity as individual DHBs seek to establish additional catheterisation laboratories and hybrid catheterisation laboratories/operating theatres.
The recommendation for sutureless AVR and TAVI to be ‘absorbed’ within the current cardiac services budget and resources is a further example of general expansion of cardiac services on a procedure-by-procedure basis. This type of incremental approach to new technologies is unsustainable and there is a real need to establish a strategic plan for cardiac services in NZ that sets a five to ten-year view of where the services should be.
National Health Committee (NHC) and Executive
The National Health Committee (NHC) is an independent statutory body which provides advice to the New Zealand Minister of Health. It was re-formed in 2011 to establish evaluation systems that would provide the New Zealand people and health sector with greater value for the money invested in health. The NHC executive are the secretariat that supports the committee. The NHC executive’s primary objective is to provide the committee with sufficient information for them to make recommendations regarding prioritisation and reprioritisation of interventions. They do this through a range of evidence-based reports tailored to the nature of the decision required and timeframe within which decisions need to be made.
Citation: National Health Committee. 2015. Aortic Stenosis: Decision Paper. Wellington: National Health Committee
Published in October 2015 by the National Health Committee
PO Box 5013, Wellington, New Zealand
ISBN (to be confirmed for final version)
(HP TBC)
This document is available on the National Health Committee’s website:
http://www.nhc.health.govt.nz/
Disclaimer
The information provided in this report is intended to provide general information to clinicians, health and disability service providers and the public, and is not intended to address specific circumstances of any particular individual or entity. All reasonable measures have been taken to ensure the quality and accuracy of the information provided. If you find any information that you believe may be inaccurate, please email to NHC_Info@nhc.govt.nz.
The National Health Committee is an independent committee established by the Minister of Health. The information in this report is the work of the National Health Committee and does not necessarily represent the views of the Ministry of Health.
The National Health Committee makes no warranty, expressed or implied, nor assumes any legal liability or responsibility for the accuracy, correctness, completeness or use of any information provided. Nothing contained in this report shall be relied on as a promise or representation by the New Zealand Government or the National Health Committee.
The contents of this report should not be construed as legal or professional advice and specific advice from qualified professional people should be sought before undertaking any action following information in this report.
Any reference to any specific commercial product, process, or service by trade name, trademark, manufacturer, or otherwise does not constitute an endorsement or recommendation by the New Zealand Government or the National Health Committee.
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