Costs and Cost Analysis

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Original Article

The Cost of Medical Management in Advanced Heart Failure: A Latin American Perspective

Livia Adams Goldraich et al. Ana Paula Beck da Silva Etges Laura Caroline Tavares Hastenteufel Dayanna Machado Lemos … Andreas Zuckermann Mandeep R. Mehra Carisi Anne Polanczyk Nadine Clausell

Abstract

Background

The financial burden faced by patients with advanced heart failure (HF) who are ineligible for heart transplantation or lack have access to advanced therapy with left ventricular assist devices (LVADs) has not been described in Latin American.

Objective

To conduct a microcosting study in patients who were otherwise eligible for LVAD therapy who did not have access to it.

Methods

We evaluated the direct costs of care in a cohort of advanced HF patients treated at a Brazilian public hospital who were candidates for LVAD therapy (and ineligible for transplantation) but lacked access to the procedure. A patient-level cost analysis was performed from the time LVAD need was identified until death or end of follow-up. The total cost per patient was calculated using the time-driven activity-based costing methodology and expressed in international dollars (Int$). Patients were stratified by disease severity and all-cause mortality to assess cost variability.

Results

Conclusions

This study highlights the financial burden associated with ongoing medical management of advanced HF in patients who would otherwise be eligible for LVAD therapy. These findings provide a basis for evaluating the cost-effectiveness of device-based, life-saving interventions in selected advanced HF populations.

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Editorial

The Hidden Cost of Denied Access: Advanced Heart Failure in Latin America

Fernanda Almeida Andrade

Advanced heart failure (AHF) represents the terminal stage of the syndrome, characterized by refractoriness to currently available pharmacological and non-pharmacological strategies. It is a condition associated with high morbidity and mortality rates and a disproportionate consumption of healthcare resources, imposing a substantial burden on both healthcare systems and families. With population aging and the increased survival of individuals with chronic heart disease, the prevalence of AHF is projected to grow steadily, with escalating impact on direct costs (hospitalizations, advanced therapies, intensive support) and indirect costs (loss of productivity and social dependency).^,

In high-income countries, costly interventions such as heart transplantation and long-term mechanical circulatory support have become consolidated therapeutic pillars that can alter the natural history of the disease. Heart transplantation remains the gold standard of treatment, although its practical application is limited by donor shortages and a high proportion of clinically ineligible patients. Within this therapeutic gap, left ventricular assist devices (LVADs) have progressively emerged as increasingly effective alternatives, particularly as destination therapy. The introduction of continuous-flow technologies and, more recently, magnetically levitated pumps, such as the HeartMate 3, has redefined prognosis, providing survival beyond five years in specialized centers.

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Original Article

Transcatheter Aortic Valve Implantation vs. Aortic Valve Surgery in a Brazilian Public Health System (SUS) Hospital: Periprocedural Outcomes and Costs

Gabriel Prado Saad et al. Alberto Collella Cervone José Henrique Delamain Vitor Belloti … Ana Paula Beck da Silva Etges Giullia Sarabando Perez Bruna Bronhara Damiani Mario Issa Farid Samaan Auristela Isabel de Oliveira Ramos Fausto Feres Dimytri Alexandre Alvim de Siqueira

Abstract

Background

Transcatheter aortic valve implantation (TAVI) has emerged as a preferred treatment for severe, symptomatic aortic stenosis (AS). However, comparative data with surgical aortic valve replacement (SAVR) within the Brazilian public health system (SUS) remain limited.

Objective

To compare clinical outcomes and perform a cost-analysis of TAVI versus SAVR in SUS patients.

Methods

This retrospective, single-center study evaluated clinical outcomes and direct medical costs, using a statistical significance threshold of 5%.

Results

Between 01/2018 and 12/2022, 320 patients (139 TAVI, 181 SAVR) were included. TAVI patients were older (77.9 vs. 64.9 years, p<0.001) and had higher surgical risk (STS 3.62% vs. 1.64%, p<0.001). Mortality (2.9% vs. 5.0%) and stroke rates (1.4% vs. 3.3%) were numerically lower for TAVI, but not statistically significant. In a risk-adjusted composite outcome (death, stroke, re-hospitalization), TAVI showed potential superiority (5.8% vs. 12%, OR 2.68, 95% CI 1.04-7.65, p=0.05), though not statistically significant. TAVI was associated with a shorter hospital stay (2.0 vs. 8.0 days, p<0.001). TAVI’s total cost was significantly higher than SAVR’s (R$ 55,750.90 [52,345.30; 92,286.80] vs R$ 22,518.10 [19,130.60; 25,875.10, – p<0.001]).

Conclusions

In this study, TAVI displayed similar clinical outcomes compared to SAVR, while being performed on older patients with higher surgical risk. From an economic perspective, costs of TAVI treatment were significantly higher than SAVR, driven mainly by device costs, while in-hospital length of stay was significantly lower. With extended follow-up and reduced procedural costs, TAVI may become a cost-effective option in the SUS.

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Editorial

Cost Implications and Perspectives of TAVI versus SAVR in the Hospital Setting

Renato Paladino Nemoto et al. Roney Orismar Sampaio

The article “Transcatheter Aortic Valve Implantation vs. Aortic Valve Surgery in a Brazilian Public Health System (SUS) Hospital: Periprocedural Outcomes and Costs” addresses a relevant topic, especially after the inclusion of transcatheter aortic valve implantation (TAVI) in the list of procedures available in the SUS. Patients undergoing TAVI are typically older, with more comorbidities, and are more frail. Conversely, surgical aortic valve replacement (SAVR) in elderly patients can result in increased morbidity and length of hospital stay.

In the study, surgical risk was low in both groups (STS 3.62±2.28 in the TAVI group vs 1.64±0.94 in SAVR, p<0.001), which may demonstrate the limitation of surgical risk stratification with current tools. Mortality was lower in the TAVI group (2.8% vs. 5.0%), but without reaching statistical significance. The minimally invasive strategy (without general anesthesia, with transthoracic echocardiography monitoring) resulted in a shorter hospital length of stay (2.0 [1.0; 4.0] days in the TAVI group vs. 8.0 [7.0; 12.0] days in the SAVR group, p<0.001). However, the costs were higher than those of SAVR. The high prices of materials (R$ 55,750.90 [52,345.30; 92,286.8] TAVI vs. R$ 22,518.10 [19,130.60; 25,875.10] SAVR, p<0.001) is a significant factor. Late complications, such as a higher rate of hospital infection, including surgical wound infection, are unfavorable to surgery, due to increased hospitalization for use of antimicrobials, hospital human resources, among other costs.

[…]

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Original Article

Cost-Utility of Venoarterial Extracorporeal Membrane Oxygenation in Refractory Cardiogenic Shock: A Brazilian Perspective Study

Sérgio Renato da Rosa Decker et al. Rodrigo Vugman Wainstein Fernando Luis Scolari Priscila Raupp da Rosa … Daniel Schneider Debora Vacaro Fogazzi Geraldine Trott Jonas Wolf Cassiano Teixeira Marciane Maria Rover Luiz Antônio Nasi Luis Eduardo Rohde Carisi Anne Polanczyk Regis Goulart Rosa Eduardo Gehling Bertoldi

Abstract

Background

Refractory cardiogenic shock (CS) is associated with high mortality rates, and the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) as a therapeutic option has generated discussions. Therefore, its cost-effectiveness, especially in low- and middle-income countries like Brazil, remains uncertain.Objectives: To conduct a cost-utility analysis from the Brazilian Unified Health System perspective to assess the cost-effectiveness of VA-ECMO combined with standard care compared to standard care alone in adult refractory CS patients.

Methods

We followed a cohort of refractory CS patients treated with VA-ECMO in tertiary care centers located in Southern Brazilian. We collected data on hospital outcomes and costs. We conducted a systematic review to supplement our data and utilized a Markov model to estimate incremental cost-effectiveness ratios (ICERs) per quality-adjusted life year (QALY) and per life-year gained.

Results

In the base-case analysis, VA-ECMO yielded an ICER of Int$ 37,491 per QALY. Sensitivity analyses identified hospitalization cost, relative risk of survival, and VA-ECMO group survival as key drivers of results. Probabilistic sensitivity analysis favored VA-ECMO, with a 78% probability of cost-effectiveness at the recommended willingness-to-pay threshold.

Conclusions

Our study suggests that, within the Brazilian Health System framework, VA-ECMO may be a cost-effective therapy for refractory CS. However, limited efficacy data and recent trials questioning its benefit in specific patient subsets highlight the need for further research. Rigorous clinical trials, encompassing diverse patient profiles, are essential to confirm cost-effectiveness and ensure equitable access to advanced medical interventions within healthcare systems, particularly in socio-economically diverse countries like Brazil.

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Original Article

Analysis of the Economic Impact of Cardiovascular Diseases in the Last Five Years in Brazil

Alessandra de Sá Earp Siqueira et al. Aristarco Gonçalves de Siqueira-Filho Marcelo Gerardin Poirot Land

Abstract

Background:

There is growing concern about the economic impact of cardiovascular diseases (CVD) in Brazil and worldwide.

Objective:

To estimate the economic impact of CVD in Brazil in the last five years.

Methods:

The information to estimate CVD costs was taken from national databases, adding the direct costs with hospitalizations, outpatient visits and benefits granted by social security. Indirect costs were added to the calculation, such as loss of income caused by CVD morbidity or mortality.

Results:

CVD mortality accounts for 28% of all deaths in Brazil in the last five years and for 38% of deaths in the productive age range (18 to 65 years). The estimated costs of CVD were R$ 37.1 billion in 2015, a 17% increase in the period from 2010 to 2015. The estimated costs of premature death due to CVD represent 61% of the total cost of CVD, Direct costs with hospitalizations and consultations were 22%, and costs related to the loss of productivity related to the disease were 15% of the total. Health expenditures in Brazil are estimated at 9.5% of GDP and the average cost of CVD was estimated at 0.7% of GDP.

Conclusion:

CVD costs have increased significantly in the last five years. It is estimated that CVD costs increase as the Brazilian population ages and the prevalence of CVD increases.

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