Brent C Lampert1, Jeffrey J Teuteberg2, Michael A Shullo2, Jonathan Holtz2, Kenneth J Smith2. 1. From the Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus (B.C.L.); Heart and Vascular Institute (J.J.T., J.H.), Pharmacy and Therapeutics (M.A.S.), and Division of General Internal Medicine (K.J.S.), University of Pittsburgh, PA. Brent.Lampert@osumc.edu. 2. From the Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus (B.C.L.); Heart and Vascular Institute (J.J.T., J.H.), Pharmacy and Therapeutics (M.A.S.), and Division of General Internal Medicine (K.J.S.), University of Pittsburgh, PA.
Abstract
BACKGROUND: Despite low risk of late rejection after heart transplant (HT), surveillance endomyocardial biopsies (EMBs) are often continued for years. We assessed the cost-effectiveness of routine EMB after 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) every 4 months during year 2 post-HT, (2) every 6 months during year 2, (3) every 4 months for years 2 to 3, and (4) every 6 months for years 2 to 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 after 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 per patient compared with the next best strategy (every 6 months for year 2) and gaining 0.0011 quality-adjusted life-years. Increasing the annual risk of asymptomatic rejection in years 2 to 3 from previously reported 2.5% to 8.5% resulted in the biopsy every 6 months for year 2 strategy gaining 0.0006 quality-adjusted life-years, but cost $4 913 599 per quality-adjusted life-year 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 per quality-adjusted life-year as that risk approached 99%. CONCLUSIONS: Surveillance EMB for 12 months post-HT is more effective and less costly than EMB performed after 12 months, unless risks of asymptomatic cellular rejection and its mortality are strikingly higher than previously observed.
BACKGROUND: Despite low risk of late rejection after heart transplant (HT), surveillance endomyocardial biopsies (EMBs) are often continued for years. We assessed the cost-effectiveness of routine EMB after 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) every 4 months during year 2 post-HT, (2) every 6 months during year 2, (3) every 4 months for years 2 to 3, and (4) every 6 months for years 2 to 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 after 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 per patient compared with the next best strategy (every 6 months for year 2) and gaining 0.0011 quality-adjusted life-years. Increasing the annual risk of asymptomatic rejection in years 2 to 3 from previously reported 2.5% to 8.5% resulted in the biopsy every 6 months for year 2 strategy gaining 0.0006 quality-adjusted life-years, but cost $4 913 599 per quality-adjusted life-year 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 per quality-adjusted life-year as that risk approached 99%. CONCLUSIONS: Surveillance EMB for 12 months post-HT is more effective and less costly than EMB performed after 12 months, unless risks of asymptomatic cellular rejection and its mortality are strikingly higher than previously observed.
Authors: David M Peng; Victoria Y Ding; Seth A Hollander; Tigran Khalapyan; John C Dykes; David N Rosenthal; Christopher S Almond; Charlotte Sakarovitch; Manisha Desai; Doff B McElhinney Journal: Pediatr Transplant Date: 2018-12-01
Authors: Nitin Chanana; Charlotte S Van Dorn; Melanie D Everitt; Hsin Yi Weng; Dylan V Miller; Shaji C Menon Journal: Pediatr Cardiol Date: 2017-02-04 Impact factor: 1.655
Authors: William Bracamonte-Baran; Nisha A Gilotra; Taejoon Won; Katrina M Rodriguez; Monica V Talor; Byoung C Oh; Jan Griffin; Ilan Wittstein; Kavita Sharma; John Skinner; Roger A Johns; Stuart D Russell; Robert A Anders; Qingfeng Zhu; Marc K Halushka; Gerald Brandacher; Daniela Čiháková Journal: Circ Heart Fail Date: 2021-09-24 Impact factor: 10.447
Authors: Ryan S Dolan; Amir A Rahsepar; Julie Blaisdell; Kai Lin; Kenichiro Suwa; Kambiz Ghafourian; Jane E Wilcox; Sadiya S Khan; Esther E Vorovich; Jonathan D Rich; Allen S Anderson; Clyde W Yancy; Jeremy D Collins; Michael Markl; James C Carr Journal: J Magn Reson Imaging Date: 2018-08-24 Impact factor: 4.813
Authors: Maria G Crespo-Leiro; Jörg Stypmann; Uwe Schulz; Andreas Zuckermann; Paul Mohacsi; Christoph Bara; Heather Ross; Jayan Parameshwar; Michal Zakliczyński; Roberto Fiocchi; Daniel Hoefer; Mario Deng; Pascal Leprince; David Hiller; Lane Eubank; Emir Deljkich; James P Yee; Johan Vanhaecke Journal: BMC Cardiovasc Disord Date: 2015-10-09 Impact factor: 2.298