title: Cost-effectiveness of ventricular assist device therapy as a bridge to transplantation compared with nonbridged cardiac recipients.
abstract: BACKGROUND
  Current available treatment options for advanced heart failure include heart transplantation and ventricular assist device (VAD) therapy. This project aimed to evaluate the cost-effectiveness of a bridge-to-transplantation (BTT)-VAD approach relative to direct heart transplantation in transplant-eligible patients.
  
  
  RESULTS
  A Markov model was used to evaluate survival benefits and costs for BTT-VAD versus nonbridged heart transplant recipients. Three different scenarios were considered according to severity of patients' baseline hemodynamic status (high, medium, and low risk). Results are presented in terms of survival, costs, and cost-effectiveness ratio. Sensitivity analyses were used to analyze uncertainty in model estimates. Over a 20-year time horizon, BTT-VAD therapy increased survival at an increased cost relative to nonbridged heart transplant recipients: $100 841more in costs and 1.19 increased life years (LYs) in high-risk patients ($84 964/LY), $112 779 more in costs and 1.14 more LYs ($99 039/LY) in medium-risk patients, and an additional cost of $144 334 and incremental clinical benefit of 1.21 more LYs ($119 574/LY) in low-risk patients. The sensitivity analysis estimated a 59%, 54%, and 43% chance of BTT-VAD therapy being cost-effective for high-, medium-, and low-risk patients at a willingness-to-pay level of $100 000/LY. Subgroup analyses indicated that risk of post-VAD and transplantation complications, waiting time, renal dysfunction, and patient age substantially affected the cost-effectiveness ratio.
  
  
  CONCLUSIONS
  BTT-VAD therapy is associated with improved survival and increased costs. On the basis of commonly accepted willingness-to-pay thresholds, BTT-VAD therapy is likely to be cost-effective relative to nonbridged heart transplantation in specific circumstances.
authors.affiliation: Toronto General Hospital, Toronto, ON, Canada. carolina.alba@uhn.ca
authors.forename: Ana C
authors.initials: AC
authors.lastname: Alba
authors.forename: Luis F
authors.initials: LF
authors.lastname: Alba
authors.forename: Diego H
authors.initials: DH
authors.lastname: Delgado
authors.forename: Vivek
authors.initials: V
authors.lastname: Rao
authors.forename: Heather J
authors.initials: HJ
authors.lastname: Ross
authors.forename: Ron
authors.initials: R
authors.lastname: Goeree
mesh_terms: D000328:Adult; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D005260:Female; D017048:Health Care Costs / Q000706:statistics & numerical data; D006333:Heart Failure / Q000191:economics* / Q000401:mortality / Q000628:therapy*; D016027:Heart Transplantation / Q000191:economics*; D006353:Heart-Assist Devices / Q000191:economics*; D006801:Humans; D008297:Male; D008390:Markov Chains; D008875:Middle Aged; D015233:Models, Statistical; D015996:Survival Rate; D014180:Transplantation; D016896:Treatment Outcome
keywords: cost–benefit analysis; economics; heart failure; heart transplantation; heart-assist devices