Cost-Effectiveness of Referring Patients to Centers of Excellence for Mitral Valve Surgery

BACKGROUND The 2014 American Heart Association/American College of Cardiology Valvular Heart Disease Guidelines state that mitral valve diseases should be repaired at a Center of Excellence (CoE). We evaluate the cost-effectiveness of such referrals. METHODS We estimate patients’ life expectancy based on projected survival of patients after mitral valve surgery and develop a cost model to calculate short- and long-term benefits and costs to both patients and payers. Benefits include increased life expectancy and avoidance of medical complications for patients. Short-term costs include all upfront payments by patients and payers at the time of discharge. Long-term costs include all payments associated with the condition that prompted the surgical procedure incurred during the remainder of a patient’s life. We assess cost-effectiveness of treating patients with various ages and major comorbidities at CoEs vs non-CoEs. RESULTS Full implementation of the guidelines would result in an increase in the percentage of patients obtaining mitral valve repair instead of valve replacement from 58% to 72%. Depending on the patient’s age and comorbidities, it would also result in a 6.64% to 12.47% reduction in mortality, 7.85% to 9.97% reduction in reoperation, 9.97% to 17.16% reduction in stroke, and an average gain of 3.77 to 9.88 months of life expectancy. Finally, greater reliance on CoEs results in financial savings to payers, due to avoidance of the costs of future complications. CONCLUSION Patients benefit from mitral valve surgery at a CoE regardless of their age or comorbidities. Payers may incur additional short-term costs when patients are referred to a CoE, but these are fully offset by long-term savings at the current repair rate gap of 24% between CoEs and non-CoEs in New York State. Redesigning co-pay structures and/or refining the set of patients who are referred to CoEs could further align the incentives of patients and payers on a case-by-case basis and achieve an even more desirable social outcome