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Original research article
Drivers of healthcare costs associated with the episode of care for surgical aortic valve replacement versus transcatheter aortic valve implantation
  1. Harindra C Wijeysundera1,2,3,4,
  2. Lindsay Li5,
  3. Vevien Braga5,
  4. Nandhaa Pazhaniappan1,
  5. Anar M Pardhan5,
  6. Dana Lian5,
  7. Aric Leeksma5,
  8. Ben Peterson6,
  9. Eric A Cohen1,
  10. Anne Forsey5 and
  11. Kori J Kingsbury5
  1. 1Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Ontario, Canada
  2. 2Institute of Health Policy, Management and Evaluation, University of Toronto, Ontario, Ontario, Canada
  3. 3Institute for Clinical Evaluative Sciences (ICES), Ontario, Ontario, Canada
  4. 4Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada
  5. 5Cardiac Care Network, Toronto, Ontario, Canada
  6. 6Royal Victoria Regional Health Centre, Barrie, Ontario, Canada
  1. Correspondence to Dr Harindra C Wijeysundera; harindra.wijeysundera{at}


Objective Transcatheter aortic valve implantation (TAVI) is generally more expensive than surgical aortic valve replacement (SAVR) due to the high cost of the device. Our objective was to understand the patient and procedural drivers of cumulative healthcare costs during the index hospitalisation for these procedures.

Design All patients undergoing TAVI, isolated SAVR or combined SAVR+coronary artery bypass grafting (CABG) at 7 hospitals in Ontario, Canada were identified during the fiscal year 2012–2013. Data were obtained from a prospective registry. Cumulative healthcare costs during the episode of care were determined using microcosting. To identify drivers of healthcare costs, multivariable hierarchical generalised linear models with a logarithmic link and γ distribution were developed for TAVI, SAVR and SAVR+CABG separately.

Results Our cohort consisted of 1310 patients with aortic stenosis, of whom 585 underwent isolated SAVR, 518 had SAVR+CABG and 207 underwent TAVI. The median costs for the index hospitalisation for isolated SAVR were $21 811 (IQR $18 148–$30 498), while those for SAVR+CABG were $27 256 (IQR $21 741–$39 000), compared with $42 742 (IQR $37 295–$56 196) for TAVI. For SAVR, the major patient-level drivers of costs were age >75 years, renal dysfunction and active endocarditis. For TAVI, chronic lung disease was a major patient-level driver. Procedural drivers of cost for TAVI included a non-transfemoral approach. A prolonged intensive care unit stay was associated with increased costs for all procedures.

Conclusions We found wide variation in healthcare costs for SAVR compared with TAVI, with different patient-level drivers as well as potentially modifiable procedural factors. These highlight areas of further study to optimise healthcare delivery.

  • Aortic stenosis
  • health care costs
  • episode of care
  • trans-catheter aortic valve implantation
  • surgical aortic valve replacement

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:

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