Elisa F Long1, Gary W Swain1, Abeel A Mangi2. 1. From Decisions, Operations & Technology Management, UCLA Anderson School of Management, Los Angeles, CA (E.F.L.); Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY (G.W.S.); and Section of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT (A.A.M.). 2. From Decisions, Operations & Technology Management, UCLA Anderson School of Management, Los Angeles, CA (E.F.L.); Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY (G.W.S.); and Section of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT (A.A.M.). abeel.mangi@yale.edu.
Abstract
BACKGROUND: Treatment options for end-stage heart failure include inotrope-dependent medical therapy, orthotopic heart transplantation (OHT), left ventricular assist device (LVAD) as destination therapy or bridge to transplant. METHODS AND RESULTS: We developed a state-transition model to simulate 4 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, 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/quality-adjusted life-year gained, relative to inotrope-dependent medical therapy. Bridge to transplant-LVAD followed by OHT further is estimated to increase life expectancy to 12.3 years, for $226,000/quality-adjusted life-year gained versus OHT. Among OHT-ineligible patients, mean life expectancy with inotrope-dependent medical therapy is estimated at 9.4 months, with 26% surviving to 1 year. Patients who instead received destination therapy-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/quality-adjusted life-year gained, relative to inotrope-dependent medical therapy. Patient's age, time on wait list, and costs associated with care influence outcomes. CONCLUSIONS: Under most scenarios, OHT prolongs life and is cost effective in eligible patients. Bridge to transplant-LVAD is estimated to offer >3.8 additional life-years for patients waiting ≥6 months, but does not meet conventional cost-effectiveness thresholds. Destination therapy-LVAD significantly improves life expectancy in OHT-ineligible patients. However, further reductions in adverse events or improved quality of life are needed for destination therapy-LVAD to be cost effective.
BACKGROUND: Treatment options for end-stage heart failure include inotrope-dependent medical therapy, orthotopic heart transplantation (OHT), left ventricular assist device (LVAD) as destination therapy or bridge to transplant. METHODS AND RESULTS: We developed a state-transition model to simulate 4 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, 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/quality-adjusted life-year gained, relative to inotrope-dependent medical therapy. Bridge to transplant-LVAD followed by OHT further is estimated to increase life expectancy to 12.3 years, for $226,000/quality-adjusted life-year gained versus OHT. Among OHT-ineligible patients, mean life expectancy with inotrope-dependent medical therapy is estimated at 9.4 months, with 26% surviving to 1 year. Patients who instead received destination therapy-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/quality-adjusted life-year gained, relative to inotrope-dependent medical therapy. Patient's age, time on wait list, and costs associated with care influence outcomes. CONCLUSIONS: Under most scenarios, OHT prolongs life and is cost effective in eligible patients. Bridge to transplant-LVAD is estimated to offer >3.8 additional life-years for patients waiting ≥6 months, but does not meet conventional cost-effectiveness thresholds. Destination therapy-LVAD significantly improves life expectancy in OHT-ineligible patients. However, further reductions in adverse events or improved quality of life are needed for destination therapy-LVAD to be cost effective.
Authors: Manreet K Kanwar; Lisa C Lohmueller; Robert L Kormos; Natasha A Loghmanpour; Raymond L Benza; Robert J Mentz; Stephen H Bailey; Srinivas Murali; James F Antaki Journal: ASAIO J Date: 2017 May/Jun Impact factor: 2.872
Authors: Anthony P Carnicelli; Anjali Thakkar; David J Deicicchi; Andrew C Storm; Jessica Rimsans; Jean M Connors; Mandeep R Mehra; John D Groarke; Michael M Givertz Journal: J Thromb Thrombolysis Date: 2019-04 Impact factor: 2.300