Comparative Survival and Cost Effectiveness of Advanced Therapies for End-stage Heart Failure
Background—Treatment options for end-stage heart failure include inotrope-dependent medical therapy (IDMT), orthotopic heart transplantation (OHT), left-ventricular assist device (LVAD) as destination therapy (DT) or bridge to transplant (BTT).
Methods and Results—We developed a state-transition model to simulate four treatment options and associated morbidity and mortality. Transition probabilities, costs, and utilities were estimated from published sources. Calculated outcomes included survival, quality-adjusted life years (QALYs), and incremental cost-effectiveness. Sensitivity analyses were performed on model parameters to test robustness. Average life expectancy for OHT-eligible patients is estimated at 1.1 years, with 39% surviving to 1-year. OHT with a median wait-time of 5.6 months is estimated to increase life expectancy to 8.5 years, and costs <$100,000/QALY gained, relative to IDMT. BTT-LVAD followed by OHT further is estimated to increase life expectancy to 12.3 years, for $226,000/QALY gained versus OHT. Among OHT-ineligible patients, mean life expectancy with IDMT is estimated at 9.4 months, with 26% surviving to 1-year. Patients who instead receive DT-LVAD are estimated to live 4.4 years on average from extrapolation of recent constant hazard rates beyond the first year. This strategy costs $202,000/QALY gained, relative to IDMT. Patient's age, time on waitlist and costs associated with care influence outcomes.
Conclusions—Under most scenarios, OHT prolongs life and is cost-effective in eligible patients. BTT-LVAD is estimated to offer more than 3.8 additional life-years for patients waiting 6 months or longer, but does not meet conventional cost-effectiveness thresholds. DT-LVAD significantly improves life expectancy in OHT-ineligible patients. However, further reductions in adverse events or improved quality-of-life are needed for DT-LVAD to be cost-effective.
- Received July 9, 2013.
- Accepted February 14, 2014.