Cost-utility analysis of heart surgeries for young adults with severe rheumatic mitral valve disease in India

Highlights

• Rheumatic heart disease is a major cause of valvular disease in young adults India.

• Surgeries for rheumatic mitral valves have inherent advantages and disadvantages.

• Our model suggests Repair is cost-effective at $2005 per QALY (India's per-capita GDP).

• The Indian public payer system should prioritize strategic purchasing for Repair.

• Bioprostheses may be cost-effective if valve durability is improved or costs reduced.

Abstract

Background

Rheumatic mitral valve disease (RMVD) is a major cause of acquired valvular disease in India. We compared the cost-effectiveness of surgical treatment strategies for young adults with severe RMVD from an Indian public payer perspective.

Methods

We developed a Markov model to reflect the burden of RMVD among a hypothetical cohort of 20-year-olds in India and to estimate quality-adjusted life years (QALYs) and lifetime costs associated with three strategies: (1) Repair; (2) Mechanical valve replacement (MVR-M); and (3) Bioprosthetic valve replacement (MVR-B), compared to a baseline strategy involving a mix of surgeries approximating the standard of care in India (32% Repair, 33% MVR-M, 35% MVR-B). Data on disease burden, intervention effects, and direct medical costs (2018 US$) were obtained from the literature. Deterministic and probabilistic sensitivity analyses were conducted to assess model uncertainty.

Results

Repair ($2530, 9.7 QALYs) was less costly and more effective than the standard of care ($2990, 8.7 QALYs) and MVR-M ($3220, 6.2 QALYs). The incremental cost-effective ratio for MVR-B ($3190, 10.1 QALYs) compared to Repair was $1590 per QALY, which may be cost-effective at a threshold of India's per-capita gross domestic product (GDP: $2005). The optimal choice between Repair or MVR-B was sensitive to variations in surgery costs, background mortality, and risks for reoperation.

Conclusions

Our model-based analysis suggests that Repair is the optimal strategy and MVR-M should not be recommended for this subpopulation. MVR-B may be cost-effective in contexts where quality of Repair is not assured, newer generation bioprostheses are used, or the costs of the bioprosthetic valve decrease.

Introduction

Rheumatic heart disease (RHD) is a major cause of acquired heart disease in young adults in low- and middle- income countries (LMICs) [1]. India accounts for the highest proportion of RHD prevalence (27%) and deaths (37%) globally [2,3]. Owing to RHD's long asymptomatic period and difficulties accessing healthcare in India, many patients present at late stages of disease, requiring surgery to circumvent heart failure and premature death [4,5].

The mitral valve is the most commonly affected valve for individuals with RHD, and guidelines indicate surgery for severe rheumatic mitral valve disease (RMVD) with [1,6]:

• Symptomatic mitral stenosis (stage D) ineligible for balloon valvuloplasty,

• Acute mitral regurgitation with uncontrolled congestive heart failure, or

• Symptomatic (stage D) or asymptomatic chronic (stage C₁ or C₂) mitral regurgitation.

Surgical interventions for the mitral valve, the most commonly affected valve, have inherent advantages and disadvantages [1,4]. Compared to valve replacements, Repair of original valve tissue is cheaper, has lower risk of complications, and avoids lifelong anticoagulation therapy, but valve damage continues and reoperation may be needed later in life [1,4,5]. Replacement surgeries involve synthetic valves that mimic original valve function. Mechanical valves are durable and may last the lifetime, but lifelong anticoagulation therapy, which carries the risk of hemorrhage, is necessary to prevent valve thrombosis and strokes [7]. Adherence to anticoagulation therapy is also difficult in populations with limited education and finances [8,9]. Bioprosthetic valves made of porcine, bovine, or human tissue require only a limited period of anticoagulation administration, but they deteriorate over time and patients may require a reoperation [7,9].

In 2018, India launched the Ayushman Bharat-National Health Protection Scheme (AB-NHPS) to provide poor households with inpatient care coverage of ₹500,000 (2018 US $7000) per year [10]. As these surgeries impose significant costs to the health system, the government must be strategic in purchasing interventions of greatest value within the limited health budget. According to a systematic review by Watkins et al. [11], there are no cost-effectiveness studies on open heart surgeries for RHD. As young working-age adults account for the majority of RHD deaths [12], we evaluated the cost-effectiveness of surgical interventions for young adults with RMVD from an Indian public payer perspective.