National economic indices and reimbursement systems determine transcatheter aortic valve implantation use in Western Europe

Purpose: Regional differences in the adoption of transcatheter aortic valve implantation (TAVI) technology have emerged since European CE mark approval in 2007. We sought to identify factors that may influence TAVI adoption and inequitable patient access in Western Europe. Methods: TAVI use was determined across 11 European nations: Germany, France, Italy, United Kingdom (UK), Spain, The Netherlands, Switzerland, Belgium, Portugal, Denmark and Ireland. The following national economic indices and healthcare parameters were assessed in order to establish factors associated with TAVI use: (1) the proportion of gross domestic product (GDP) spent on healthcare; (3) the total healthcare expenditure (US dollars) per capita; (4) the principal source of healthcare funding (social insurance or taxation); and (5) the system of TAVI reimbursement (TAVI-specific or constrained). Results: Between 2007-2011, a cumulative total of 34504 patients underwent TAVI in the 11 study nations. Significant linear correlations were found between TAVI utilisation and healthcare spending as a percentage of GDP (r=0.68, p=0.025), and healthcare spending per capita (r=0.80, p=0.005). There was a trend towards increased TAVI use in those nations where healthcare was funded principally by social insurance (Germany, France, the Netherlands, Switzerland, and Belgium) compared to those principally funded by taxation (Italy, UK, Spain, Portugal, Denmark, Ireland) (571±290 versus 252±192 implants per million ≥75 years, p=0.056). TAVI reimbursement strategies across the study nations were heterogeneous. TAVI-specific national DRG-based reimbursement occurs in Germany, France, Switzerland, and Denmark. Constrained reimbursement systems were noted for the UK, Spain, the Netherlands, Belgium, Portugal and Ireland where the cost of TAVI is borne by a local healthcare trust (UK) or by the hospital budget. TAVI-specific reimbursement systems were associated with a 3.3-fold higher TAVI utilisation than constrained systems (698±232 versus 213±112, p=0.002). Furthermore, TAVI-specific reimbursement systems were associated with 2.5 times more TAVI implants per centre than constrained systems (69±18 vs. 26±20 implants per centre p=0.008). Conclusions: National economic indices and reimbursement strategies are closely linked with TAVI use and may explain the inequitable adoption of TAVI across nations.