Cost Effectiveness of Routine Surveillance Endomyocardial Biopsy Beyond 12 Months Post Heart Transplantation
Background—Despite low risk of late rejection after heart transplant (HT), surveillance endomyocardial biopsies (EMB) are often continued for years. We assessed the cost-effectiveness of routine EMB beyond 12 months post-HT.
Methods and Results—Markov model compared the following surveillance EMB strategies to baseline strategy of stopping EMB 12 months post-HT: 1.) q 4 months during year 2 post-HT, 2.) q 6 months during year 2; 3.) q 4 months for years 2-3, and 4.) q 6 months for years 2-3. Patients entered the model 12 months post-HT and were followed until 36 months. In all strategies, patients had EMB with symptoms; in biopsy strategies beyond 12 months, EMB was also performed as scheduled regardless of symptoms. One-way and Monte Carlo sensitivity analyses were performed. Stopping EMB at 12 months was dominant (more effective, less costly), saving $2884/patient compared to the next best strategy (q 6 months for year 2) and gaining 0.0011 QALYs. Increasing the annual risk of asymptomatic rejection in years 2-3 from previously reported 2.5% to 8.5% resulted in the biopsy q 6 months for year 2 strategy gaining 0.0006 QALYs, but cost $4,913,599/QALY gained. EMB for 12 months was also no longer dominant when mortality risk from untreated asymptomatic rejection approached 11%; competing strategies still cost >$200,000/QALY as that risk approached 99%.
Conclusions—Surveillance EMB for 12 months post-HT is more effective and less costly than EMB performed beyond 12 months, unless risks of asymptomatic cellular rejection and its mortality are strikingly higher than previously observed.
- Received February 26, 2014.
- Accepted July 24, 2014.