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A Systematic Review of Cost-Effectiveness Analyses of Left Ventricular Assist Devices: Issues and Challenges

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Abstract

Background

Advanced heart failure (HF) can be treated conservatively or aggressively, with left ventricular assist devices (LVADs) and heart transplant (HT) being the most aggressive strategies.

Objective

The goal of this review was to identify, describe, critique and summarize published cost-effectiveness analyses on LVADs for adults with HF.

Methods

We conducted a literature search using PubMed and ProQuest DIALOG databases to identify English-language publications from 2006 to 2017 describing cost-effectiveness analyses of LVADs and reviewed them against inclusion criteria. Those that met criteria were obtained for full-text review and abstracted if they continued to meet study requirements.

Results

A total of 12 cost-effectiveness studies (13 articles) were identified, all of which described models; they were almost evenly split between those examining LVADs as destination therapy (DT) or as bridge to transplant (BTT). Studies were Markov or semi-Markov models with one- or three-month cycles that followed patients until death. Inputs came from a variety of sources, with the REMATCH trial and INTERMACS registry common clinical data sources, although some publications also used data from studies at their own institutions. Costs were derived from standard sources in many studies but from individual hospital data in some. Inputs for health utilities, which were used in 11 of 12 studies, were generally derived from two studies. None of the studies reported a societal perspective, that is, included non-medical costs such as caregiving.

Conclusions

No study found LVADs to be cost effective for DT or BTT with base case assumptions, although incremental cost-effectiveness ratios met thresholds for cost effectiveness in some probabilistic analyses. With constant improvements in LVADs and expanding indications, understanding and re-evaluating the cost effectiveness of their use will be critical to making treatment decisions.

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Data availability

All of the publications cited in this literature review are available to the public. Some are available as open access (freely available) documents, while some must be purchased.

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Authors and Affiliations

  1. Exponent Inc, 1800 Diagonal Rd., Suite 500, Alexandria, VA, 22314, USA

    Jordana K. Schmier

  2. Exponent Inc, 3440 Market Street, Suite 600, Philadelphia, PA, 19104, USA

    Jasmine D. Patel & Prem A. Midha

  3. Exponent, Inc, 15375 SE 30th Place, Suite 250, Bellevue, WA, 98007, USA

    Megan J. Leonhard

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  1. Jordana K. Schmier
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Contributions

All authors (JS, ML, JP, and PM) were involved with the design of the search strategy. JS and ML reviewed search results in detail to refine terms. JS completed the initial abstraction; ML provided QC. JP and PM provided insight on interpretation and organization of the text based on clinical knowledge. JS outlined the manuscript and developed a first draft of the Methods and Results sections and paragraphs on limitations; JP and PM drafted the Introduction and clinically-focused sections of the Conclusions. ML provided a critical review and revisions on the entire manuscript. All authors reviewed and approved the final submission.

Corresponding author

Correspondence to Jordana K. Schmier.

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Funding

No funding was received for this analysis.

Conflict of interest

The authors (JS, ML, JP, and PM) report no conflicts of interest.

Electronic supplementary material

Below is the link to the electronic supplementary material.

40258_2018_439_MOESM1_ESM.xlsx

Electronic Supplementary Material A. Consolidated Health Economic Evaluation Reporting (CHEERS) Checklist for Included Articles (XLSX 18 kb)

Electronic Supplementary Material B. Characteristics of Included Articles (DOCX 38 kb)

Appendix: Papers Abstracted for Review

Appendix: Papers Abstracted for Review

Alba AC, Alba LF, Delgado DH, Rao V, Ross HJ, Goeree R. Cost-effectiveness of ventricular assist device therapy as a bridge to transplantation compared with nonbridged cardiac recipients. Circulation 2013; 127: 2424-2435

Baras Shreibati J, Goldhaber-Fiebert JD, Banerjee D, Owens DK, Hlatky MA. Cost-effectiveness of left ventricular assist devices in ambulatory patients with advanced heart failure. JACC Heart Failure 2017; 5: 110-119

Chew DS, Manns B, Miller RJH, Sharma N, Exner DV. Economic evaluation of left ventricular assist devices for patients with end stage heart failure who are ineligible for cardiac transplantation. The Canadian Journal of Cardiology 2017; 33: 1283-1291

Clarke A, Pulikottil-Jacob R, Connock M, Suri G, Kandala NB, Maheswaran H, Banner NR, Sutcliffe P. Cost-effectiveness of left ventricular assist devices (LVADs) for patients with advanced heart failure: analysis of the British NHS bridge to transplant (BTT) program. International Journal of Cardiology 2014; 171: 338-345

Long EF, Swain GW, Mangi AA. Comparative survival and cost-effectiveness of advanced therapies for end-stage heart failure. Circulation Heart Failure 2014; 7: 470-478

Moreno SG, Novielli N, Cooper NJ. Cost-effectiveness of the implantable HeartMate II left ventricular assist device for patients awaiting heart transplantation. The Journal of Heart and Lung Transplantation 2012; 31: 450-458

Neyt M, Van den Bruel A, Smit Y, De Jonge N, Erasmus M, Van Dijk D, Vlayen J. Cost-effectiveness of continuous-flow left ventricular assist devices. International Journal of Technology Assessment in Health Care 2013; 29: 254-260

Pulikottil-Jacob R, Suri G, Connock M, Kandala NB, Sutcliffe P, Maheswaran H, Banner NR, Clarke A. Comparative cost-effectiveness of the HeartWare versus HeartMate II left ventricular assist devices used in the United Kingdom National Health Service bridge-to-transplant program for patients with heart failure. The Journal of Heart and Lung Transplantation 2014; 33: 350-358

Rogers JG, Bostic RR, Tong KB, Adamson R, Russo M, Slaughter MS. Cost-effectiveness analysis of continuous-flow left ventricular assist devices as destination therapy. Circulation Heart Failure 2012; 5: 10-16

Sharples LD, Dyer M, Cafferty F, Demiris N, Freeman C, Banner NR, Large SR, Tsui S, Caine N, Buxton M. Cost-effectiveness of ventricular assist device use in the United Kingdom: results from the evaluation of ventricular assist device programme in the UK (EVAD-UK). The Journal of Heart and Lung Transplantation 2006; 25: 1336-1343

Sutcliffe P, Connock M, Pulikottil-Jacob R, Kandala NB, Suri G, Gurung T, Grove A, Shyangdan D, Briscoe S, Maheswaran H, Clarke A. Clinical effectiveness and cost-effectiveness of second- and third-generation left ventricular assist devices as either bridge to transplant or alternative to transplant for adults eligible for heart transplantation: systematic review and cost-effectiveness model. Health Technol Assess 2013; 17: 1-499, v-vi

Tadmouri A, Blomkvist J, Landais C, Seymour J, Azmoun A. Cost-effectiveness of left ventricular assist devices for patients with end-stage heart failure: analysis of the French hospital discharge database. ESC Heart Failure 2018;5(1):75-86.

Takura T, Kyo S, Ono M, Tominaga R, Miyagawa S, Tanoue Y, Sawa Y. Preliminary report on the cost effectiveness of ventricular assist devices. Journal of Artificial Organs 2016; 19: 37-43

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Schmier, J.K., Patel, J.D., Leonhard, M.J. et al. A Systematic Review of Cost-Effectiveness Analyses of Left Ventricular Assist Devices: Issues and Challenges. Appl Health Econ Health Policy 17, 35–46 (2019). https://doi.org/10.1007/s40258-018-0439-x

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