Cost–effectiveness of left ventricular-assist devices in end-stage heart failure

Abstract

With a limited supply of donor hearts, individuals with end-stage heart failure have been offered hope through the use of mechanical devices. Left ventricular-assist devices (LVADs) are a technology designed to work in parallel with the heart but have yet to see widespread use since uncertainty remains as to the cost–effectiveness of this evolving new technology. We have systematically reviewed evidence of cost–effectiveness for LVADs in the bridge-to-transplant and long-term chronic support indications. A total of 18 studies reporting costs were identified. Of these, only four studies reported results in cost–effectiveness terms; two in cost per life-year saved and two in cost per quality-adjusted life-year (QALY). The majority of the other studies were simple cost summations (cost per day or incremental cost) without consideration of efficacy. In the bridge-to-transplant indication, a Danish abstract reported a cost per life-year saved of DKK270k (US$48,000), a UK study reported a cost per QALY of GB£39,787 (US$78,000) and a Canadian study reported a cost per life-year saved of Can$91,332 (US$86,000). Regarding the long-term chronic support indication, the same Canadian study reported a cost per life-year saved of Can$59,842 (US$56,000), whereas a US study reported a cost per QALY of $36,255–60,057. Assuming a willingness to pay the threshold of GB£30,000 (US$59,000) per QALY, there is arguably stronger evidence to support the cost–effectiveness of LVAD technology for the long-term chronic support indication. However, the methodological quality of the majority of studies was poor, as was their generalizability, raising concerns over the reliability of these figures. With the limited and declining availability of donor hearts for transplantation, it appears that the future of this technology is in its use as long-term chronic support. Further analyses should be undertaken, particularly alongside randomized, controlled trials and utilizing second- and third-generation devices.

Keywords::

• cost–effectiveness
• end-stage heart failure
• Heartmate^®
• left ventricular-assist device
• mechanical circulatory support
• Novacor^®
• quality-adjusted life-year

Acknowledgements

We thank the advisory group for this study for advice and peer review of a draft of the original report for the NHS R&D HTA Programme, including: Professor S Ball, Leeds General Infirmary, Leeds, UK; Professor Martin Buxton, University of Brunel, UK; Ms Noreen Caine, Papworth Hospital NHS Trust, Cambridge, UK; Professor J Cleland, University of Hull, Hull, UK; Dr Mick Davies, University Hospital Birmingham NHS Trust, Birmingham, UK; Mr Stephen Large, Papworth Hospital NHS Trust, Cambridge, UK; Dr S Ludgate, Medicines and Healthcare Products Regulatory Agency, London, UK; Dr P McCarthy, Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic, Cleveland, USA; Dr A Moskowitz, INCHOIR, Columbia University, New York, USA; Professor John Pepper, Royal Brompton Hospital, London, UK; Dr L Vale, Health Economics Research Unit, University of Aberdeen, Aberdeen, UK; Mr Stephen Westaby, John Radcliffe Hospital, Oxford, UK; Professor Sir MH Yacoub, Imperial College London and The Magdi Yacoub Institute NHLI at Heart Science Centre, Harefield, Middlesex, UK. In addition, we would like to acknowledge several people who provided data, translated papers or assisted in extracting data for this study, including: J Fawell, Papworth Hospital NHS Trust, Cambridge, UK; Liz Hodson, University of Southampton, UK; Dr Christine Clar, Germany; Sian Thomas, Orkney Isles, UK; Mariam Brazzelli, University of Aberdeen, Aberdeen, UK; Sacci Thomas, Winshester, UK; Dr Goro Matsumiya, Osaka University Graduate School of Medicine, Japan; Dr Deereck Wheeldon, WorldHeart, UK; Dr Charles Glanville, Thoratec Europe Ltd, Cambridge, UK; Karen Brennan, Thoratec Europe Ltd, Cambridge, UK; Dr P Jansen, Jarvik Heart Inc, New York, USA; Dr Janine Meehan, Jarvik Heart Inc, New York, USA; Dallas Anderson, MicroMed Technology Inc. Houston, Texas, USA; Yosuke Kobayashi, Toyobo Co Ltd, Osaka, Japan; Dr Bill Gutteridge, Medical Adviser, NSCAG, Department of Health, London, UK; Dr N Banner, Royal Brompton and Harefield NHS Trust, London, UK.

We would also like to thank the three anonymous referees for their comments on an earlier draft of this paper.

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.