Comparing approval, adoption/de-adoption and outcomes for advanced cardiovascular procedures across high-income countries

Project Summary In 2011 the Institute of Medicine (now the National Academy of Medicine) convened a panel to explore the paradox of why the US spends more on healthcare than other developed countries yet has inferior outcomes. It concluded that “Data are simply lacking to fully understand the causal factors responsible for each of the diseases and injuries that disproportionately affect the US population.” This is still true today. What’s notable is that the US has shorter life expectancy with the 2nd highest cardiovascular death rate among peer countries while still having the highest spending in the world (19.7% of gross domestic product). In 2019 Drs. Cram and Landon founded the International Health Systems Research Collaborative (IHSRC) with funding from the NIH (NIA R01AG058878) to compare treatment and outcomes across high-income countries for cohorts of patients defined by common diagnoses and procedures. The current proposal will leverage and expand upon our IHSRC infrastructure to compare health technology assessment (HTA) across countries and evaluate how HTA relates to the utilization, adoption, and de-adoption of new cardiovascular (CV) treatments and procedures. Many countries (including IHSRC members England, Netherlands and Canada) have explicit HTA processes linked to public insurance coverage decisions for new therapies. The US is notable for lacking a formal HTA process. While failure to embrace HTA likely contributes to excessively high spending in the US, few studies have evaluated how different countries approach HTA. The overarching objective of our research is to understand how advanced CV therapies are adopted and used in 7 countries with advanced healthcare systems. Our research will focus on 3 cardiovascular condition dyads where introduction/refinements in advanced therapy is disrupting an established therapy: 1) aortic valve dysfunction where transcatheter aortic valve replacement (TAVR) is in the process of supplanting surgical aortic valve replacement (SAVR); 2) elective AAA repair where endovascular aneurysm repair is replacing open repair; and 3) carotid artery stenosis where trans-carotid artery revascularization (TCAR) and stenting are emerging as substitutes for carotid endarterectomy. Our research will address major unanswered questions by providing crucial insights into how advanced technologies are adopted and used in different countries. We will provide much needed clarity with respect to the ongoing and unanswered question of whether higher spending in the US can be attributed to more rapid adoption and higher utilization of advanced therapies. Our proposal has three specific aims that assess: (1) each country’s policy and health technology assessment environment related to each procedure; (2) technology diffusion patterns in the context of their evolving policy environments; and (3) differences in outcomes, including mortality, readmissions, and hospital-free days at home. The scientific premise of our proposal is that granular information is needed to inform the study of comparative health systems and to understand the adoption and diffusion of new technologies.