title: Cost-effectiveness of left ventricular assist devices (LVADs) for patients with advanced heart failure: analysis of the British NHS bridge to transplant (BTT) program.
abstract: BACKGROUND
  A previous cost-effectiveness analysis showed that bridge to transplant (BTT) with early design left ventricular assist devices (LVADs) for advanced heart failure was more expensive than medical management while appearing less beneficial. Older LVADs were pulsatile, but current second and third generation LVADs are continuous flow pumps. This study aimed to estimate comparative cost-effectiveness of BTT with durable implantable continuous flow LVADs compared to medical management in the British NHS.
  
  
  RESULTS
  A semi-Markov multi-state economic model was built using NHS costs data and patient data in the British NHS Blood and Transplant Database (BTDB). Quality-adjusted life years (QALYs) and incremental costs per QALY were calculated for patients receiving LVADs compared to those receiving inotrope supported medical management. LVADs cost £80,569 ($127,887) at 2011 prices and delivered greater benefit than medical management. The estimated probabilistic incremental cost-effectiveness ratio (ICER) was £53,527 ($84,963)/QALY (95%CI: £31,802-£94,853; $50,479-$150,560) (over a lifetime horizon). Estimates were sensitive to choice of comparator population, relative likelihood of receiving a heart transplant, time to transplant, and LVAD costs. Reducing the device cost by 15% decreased the ICER to £50,106 ($79,533)/QALY.
  
  
  CONCLUSIONS
  Durable implantable continuous flow LVADs deliver greater benefits at higher costs than medical management in Britain. At the current UK threshold of £20,000 to £30,000/QALY LVADs are not cost effective but the ICER now begins to approach that of an intervention for end of life care recently recommended by the British NHS. Cost-effectiveness estimates are hampered by the lack of randomized trials.
authors.affiliation: Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, United Kingdom. Electronic address: aileen.clarke@warwick.ac.uk.
authors.forename: Aileen
authors.initials: A
authors.lastname: Clarke
authors.affiliation: Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, United Kingdom.
authors.forename: Ruth
authors.initials: R
authors.lastname: Pulikottil-Jacob
authors.affiliation: Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, United Kingdom.
authors.forename: Martin
authors.initials: M
authors.lastname: Connock
authors.affiliation: Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, United Kingdom.
authors.forename: Gaurav
authors.initials: G
authors.lastname: Suri
authors.affiliation: Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, United Kingdom.
authors.forename: Ngianga-Bakwin
authors.initials: NB
authors.lastname: Kandala
authors.affiliation: Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, United Kingdom.
authors.forename: Hendramoorthy
authors.initials: H
authors.lastname: Maheswaran
authors.affiliation: National Heart Lung Institute, Imperial College, London, United Kingdom.
authors.forename: Nicholas R
authors.initials: NR
authors.lastname: Banner
authors.affiliation: Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, United Kingdom.
authors.forename: Paul
authors.initials: P
authors.lastname: Sutcliffe
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D003362:Cost-Benefit Analysis; D005260:Female; D005500:Follow-Up Studies; D006333:Heart Failure / Q000191:economics* / Q000401:mortality / Q000601:surgery*; D016027:Heart Transplantation / Q000191:economics* / Q000401:mortality / Q000639:trends; D006352:Heart Ventricles; D006353:Heart-Assist Devices / Q000191:economics* / Q000639:trends; D006801:Humans; D008297:Male; D008390:Markov Chains; D008875:Middle Aged; D015996:Survival Rate / Q000639:trends; D006113:United Kingdom / Q000453:epidemiology; D055815:Young Adult
keywords: Comparative cost-effectiveness; Heart failure; Left ventricular assist device