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News & Trends - MedTech & Diagnostics

Heart of the matter: The ethical dilemma amidst Australia’s TAVI access divide

Health Industry Hub | February 28, 2024 |

MedTech & Diagnostics News: In a thought-provoking perspective piece, an Australian Cardiothoracic Surgeon sheds light on the role of Health Technology Assessment (HTA) in the integration of transcatheter aortic valve implantation (TAVI) into Australia’s healthcare system. Prince of Wales Hospital’s Dr Jonathon Ryan reveals structural flaws hindering equity, sparking a debate on the accessibility and ethical considerations surrounding this disruptive technology.

Aortic stenosis, the most prevalent form of valvular heart disease, historically relied on surgical aortic valve replacement (SAVR). However, a substantial portion of patients, primarily due to advanced age and frailty, found SAVR unsuitable. This unmet need paved the way for the development of transcatheter aortic valve implantation (TAVI), a less invasive procedure performed through the femoral artery. Since its inception in 2002, TAVI has progressively replaced SAVR, becoming the preferred choice for younger and healthier patients.

Despite the higher initial cost of TAVI valves compared to SAVR valves, the overall implantation cost of TAVI proves more economical than performing SAVR. However, concerns loom over the long-term durability of TAVI, a factor already well-established in SAVR.

Since 1 July 2022, TAVI has been included on the Medical Benefits Scheme (MBS) for patients with symptomatic severe aortic stenosis at low surgical risk, following a positive recommendation by the Medical Services Advisory Committee (MSAC) a year earlier.

However, there is inequitable access across the country with NSW Health behind the rest of the country. “Who should get the last TAVI valve?” is an ethical dilemma that heart teams at many state‐run public hospitals routinely grapple with, according to Dr Ryan.

Edwards Lifesciences is spearheading a campaign in NSW to drive the adoption of minimally invasive Transcatheter Aortic Valve Implantation (TAVI).

Notably, patients with private health insurance (gold and silver policy holders) are guaranteed federally subsidised TAVI, resulting in a disproportionate number of private TAVI cases. This stark contrast in access levels led to ~1440 public patients being unable to access TAVI in 2021–2022.

The root of the issue lies in the constitutional and inter-governmental divisions. While state governments directly manage public hospital activities, the federal government indirectly oversees private hospital activities. The resultant inconsistencies are exacerbated by significant fiscal imbalances between the two levels of government, creating a complex web of agreements governing transfer payments.

Dr Ryan advocates for a bridging solution through a nationally cohesive HTA approach. The current National Health Reform Agreement (NHRA) recognises the need for such an approach, yet Dr Ryan argues that the existing roadmap falls short. The fragmented approach to HTA, if preserved, and the disjointed decisions made by state and federal governments, will perpetuate public-private access gaps.

The pressing solution, according to Dr Ryan, is a truly national body that conducts HTA from both state and federal perspectives. This proactive entity should act as a facilitator, providing advice to both health ministers in a manner that supports joint decision-making in intergovernmental forums. Only through unified advice can policymakers comprehend the varying implications of funding new technology in both public and private healthcare systems, allowing them to develop implementation strategies that guarantee equitable access for all, irrespective of postcode and socioeconomic status.

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