Abstract
Herein, we describe the unique interplay among biomedical ethics, principles of distributive
justice, and economic theory to highlight the role of health technology assessments
to compare therapeutic options for aortic valve replacement. From the perspective
of the Canadian health care system, transcatheter aortic-valve implantation is associated
with higher costs but also higher incremental health benefits compared with surgical
aortic-valve replacement. At current willingness to pay thresholds, transcatheter
aortic-valve replacement is likely cost effective across the spectrum of risk, from
inoperable patients to those at low surgical risk. However, we highlight the nuances
within each subgroup of surgical risk that merit careful consideration by the heart
team. Moreover, incorporation of patients and their preferences in decision-making
is key. In particular, in young, low-risk patients, there remains uncertainty regarding
the optimal treatment, with unique concerns around valve durability, selection of
valve prosthesis, and consideration for special procedures such as the Ross procedure.
Nonetheless, current research suggests that, universally, patients prefer a less invasive
approach compared with a more invasive approach. Finally, we highlight that there
remain critical issues around timeliness of access to care and unacceptable geographic
inequities across Canada. Further research into alternative funding mechanisms and
integrated cross-sector care pathways is necessary to address these issues.
Résumé
Nous décrirons ci-après l'interaction unique entre l'éthique biomédicale, les principes
de justice distributive et la théorie économique afin de souligner le rôle des évaluations
des technologies de la santé dans la comparaison des options thérapeutiques pour le
remplacement valvulaire aortique. Du point de vue du système de soins de santé canadien,
l'implantation valvulaire aortique par cathéter est associée à des coûts plus élevés,
mais aussi à des bienfaits différentiels accrus en matière de santé, comparativement
à la chirurgie de remplacement valvulaire aortique. Selon les seuils de disposition
à payer actuels, l'implantation valvulaire aortique par cathéter est est probablement
une approche rentable pour les patients à divers stades du spectre de risque, en allant
des patients inopérables à ceux chez qui le risque chirurgical est faible. Toutefois,
nous soulignons les nuances au sein de chacun des sous-groupes de risque chirurgical
qui méritent d'être soigneusement prises en considération par l'équipe de cardiologie.
De plus, il est essentiel de tenir compte des patients et de leurs préférences dans
le processus décisionnel. Chez les patients jeunes à faible risque, particulièrement,
le traitement optimal demeure incertain, et certaines préoccupations concernant la
durabilité de la valve, le choix de la prothèse valvulaire et la possibilité de recourir
à une intervention spéciale, comme la procédure de Ross, sont propres à ce sous-groupe.
La recherche actuelle suggère néanmoins que de façon universelle, les patients préfèrent
une approche moins invasive à une approche plus invasive. Finalement, nous rappellerons
qu'il subsiste encore des enjeux importants concernant les temps d'attente pour l'accès
aux soins et des inégalités géographiques inacceptables au sein du Canada. De plus
amples recherches sont requises pour trouver d’autres mécanismes de financement et
des approches transversales de soins intégrés afin de remédier à ces enjeux.
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Article info
Publication history
Published online: April 30, 2021
Accepted:
November 27,
2020
Received:
September 27,
2020
Footnotes
See page 1001 for disclosure information.
Identification
Copyright
© 2020 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
