Samson D, Garber A, Sanders G, Aronson N; AcademyHealth. Meeting (2004 : San Diego, Calif.).
Abstr AcademyHealth Meet. 2004; 21: abstract no. 2042.
Blue Cross and Blue Shield Association, Technology Evaluation Center, 1310 G Street, N.W., Washington, DC 20005 Tel. 202.626.4835 Fax 845.462.4786
RESEARCH OBJECTIVE: This project compared the cost-effectiveness of left-ventricular assist devices used as permanent implants (as destination therapy) and optimal medical management for patients with end-stage heart failure who are not candidates for cardiac transplantation. Left-ventricular assist devices (LVADs) augment impaired cardiac pumping ability. STUDY DESIGN: This cost-effectiveness analysis used quality-adjusted life-years (QALYs) as the metric used for summarizing the effectiveness of health strategies, taking into account all healthcare costs. A simple Markov model was used that included two health states, alive and dead. The Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure (REMATCH) trial compared LVADs with optimal medical management in 129 patients. The REMATCH trial reported a 48% reduction in the risk of death for LVAD patients. The alive state was weighted for quality (utility) by New York Heart Association (NYHA) class categories (I/II or III/IV), which classify functioning with heart failure. Monthly additions to costs were derived from the probability of surviving, the probability of being rehospitalized versus being an outpatient and the associated costs of each. The analysis assumed that the average cost of implanting the LVAD is approximately $270,000, the average cost of being rehospitalized for 1 month is about $40,000 and the cost of 1 month of outpatient care is around $1,700. It was also assumed that all patients would be dead at the end of 3 years and the cost of rehospitalization and outpatient care would be the same for LVAD and optimal medical management. Sensitivity analyses were performed on multiple variables including: utilities, costs, probabilities of rehospitalization, discount rates, and the relative survival experience of LVAD and optimal medical management. POPULATION STUDIED: This analysis applies to patients meeting the REMATCH trial selection criteria. These end-stage heart failure patients may be excluded from heart transplantation due to advanced age (over 65 years), or other major comorbidities such as insulin-dependent diabetes mellitus and chronic renal failure. PRINCIPAL FINDINGS: The incremental cost effectiveness ratio (ICER) is the increase in cost required to gain 1 QALY, by using LVAD compared with optimal medical management. In the baseline cost-effectiveness analysis, the ICER was approximately $800,000. The sensitivity analysis based on uncertainty about the relative survival of LVAD and optimal medical management showed that the ICERs could vary between $500,000 per QALY and $1,400,000 per QALY. Results also appeared to be highly influenced by the cost of initial hospitalization for LVAD implantation. ICERs of $500,000/QALY or less could only be achieved by making quite improbable assumptions that the cost of LVAD implantation is half the average cost or less and that LVADs achieve survival past 3 years in a substantial proportion of patients, well beyond the survival observed in the REMATCH trial. CONCLUSIONS: These findings indicate that use of LVADs as destination therapy for end-stage heart failure in patients ineligible for heart transplantation exceeds common standards of cost-effectiveness. IMPLICATIONS FOR POLICY, DELIVERY OR PRACTICE: Use of LVADs in this setting raises economic and societal issues of resource allocation for end-of-life care.
Publication Types:
Keywords:
- Clinical Trials as Topic
- Cost-Benefit Analysis
- Heart Failure
- Heart Transplantation
- Heart-Assist Devices
- Hospitalization
- Humans
- Length of Stay
- New York
- Patient Selection
- Research
- economics
- instrumentation
- methods
- surgery
- therapy
- transplantation
- hsrmtgs
UI: 103625076
From Meeting Abstracts