title: A value-based analysis of hemodynamic support strategies for high-risk heart failure patients undergoing a percutaneous coronary intervention.
abstract: BACKGROUND
  The economic burden of heart disease is heavy and growing. As advanced technologies for treating heart disease become available, decision makers need to be able to assess the relative value of such options against existing standards of care.
  
  
  OBJECTIVE
  To compare the clinical and economic benefits of a percutaneous ventricular assist device (pVAD) versus an intra-aortic balloon pump (IABP) observed during the 90-day duration of the PROTECT II clinical trial, and to supplement these findings with a simulation of the longer-term value of this technology through the use of a Markov model to estimate the incremental cost-effectiveness of a pVAD relative to an IABP, in terms of quality-adjusted life-years (QALYs).
  
  
  METHODS
  Hospital bills were collected for patients enrolled in the PROTECT II trial who received hemodynamic support for high-risk percutaneous coronary intervention (PCI) provided by a pVAD (Impella 2.5) versus a conventional IABP during a 90-day episode of care (EOC). Length of stay, charges, and costs were analyzed for the index admissions, intensive care unit confinements, readmissions, and overall EOC. In addition, a probabilistic Markov model was used to project these parameters and their impact on a patient's quality of life for up to 10 years in relation to a pVAD versus an IABP.
  
  
  RESULTS
  Hospital costs for the index admission were lower for the IABP compared with the pVAD ($33,684 vs $47,667; P <.001), whereas readmission length of stay and costs were lower for the pVAD versus the IABP (5 days vs 7 days; and $11,007 vs $21,834, respectively; P <.001). The total 90-day hospital charges were similar for the pVAD and the IABP ($172,564 vs $172,758, respectively; P = .785); however, the total 90-day EOC cost was lower for the IABP than for the pVAD ($44,032 vs $53,171, respectively; P <.001). The median hospital days for the entire EOC were 7 days for the pVAD versus 9 days for the IABP (P = .008). Critical care stays were considerably shorter for a pVAD than for an IABP on readmissions (3.88 days vs 7.00 days; P = .145). Reduction in major adverse cardiovascular and cerebrovascular events resulted in a projected gain of 0.26 QALYs over 10 years, yielding an incremental cost-effectiveness ratio of $39,389/QALY.
  
  
  CONCLUSIONS
  For high-risk patients with advanced heart failure undergoing PCI, the new pVAD reduced major adverse events, critical care and readmission length of stay, and readmission cost over the 90-day EOC, and was determined to be cost-effective over the long-term. These findings can assist decision makers in forming value-based judgments with regard to new hemodynamic support strategies.
authors.affiliation: Executive Vice President and Partner, Presscott Associates, a Division of ParenteBeard, LLC, New York, NY.
authors.forename: David
authors.initials: D
authors.lastname: Gregory
authors.affiliation: The Alfred E. Driscoll Professor of Healthcare & Life Sciences Management, Fairleigh Dickinson University, Teaneck, NJ.
authors.forename: Dennis J
authors.initials: DJ
authors.lastname: Scotti
authors.affiliation: Adjunct Associate Professor, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
authors.forename: Gregory
authors.initials: G
authors.lastname: de Lissovoy
authors.affiliation: Director, Cardiac Catheterization Lab, Massachusetts General Hospital, Boston, MA.
authors.forename: Igor
authors.initials: I
authors.lastname: Palacios
authors.affiliation: Chair, Cardiovascular Medicine, Beaumont Health System, Royal Oak, MI.
authors.forename: Simon
authors.initials: S
authors.lastname: Dixon
authors.affiliation: Director, Advanced Cardiac & Endovascular Interventional Laboratory, Cardiovascular Research & Education, PinnacleHealth, Wormleysburg, PA.
authors.forename: Brijeshwar
authors.initials: B
authors.lastname: Maini
authors.affiliation: Medical Director, Center for Structural Heart Disease, Henry Ford Hospital, Detroit, MI.
authors.forename: William
authors.initials: W
authors.lastname: O'Neill