title: Cost-effectiveness of routine surveillance endomyocardial biopsy after 12 months post-heart transplantation.
abstract: BACKGROUND
  Despite low risk of late rejection after heart transplant (HT), surveillance endomyocardial biopsies (EMBs) are often continued for years. We assessed the cost-effectiveness of routine EMB after 12 months post-HT.
  
  
  RESULTS
  Markov model compared the following surveillance EMB strategies to baseline strategy of stopping EMB 12 months post-HT: (1) every 4 months during year 2 post-HT, (2) every 6 months during year 2, (3) every 4 months for years 2 to 3, and (4) every 6 months for years 2 to 3. Patients entered the model 12 months post-HT and were followed until 36 months. In all strategies, patients had EMB with symptoms; in biopsy strategies after 12 months, EMB was also performed as scheduled regardless of symptoms. One-way and Monte Carlo sensitivity analyses were performed. Stopping EMB at 12 months was dominant (more effective, less costly), saving $2884 per patient compared with the next best strategy (every 6 months for year 2) and gaining 0.0011 quality-adjusted life-years. Increasing the annual risk of asymptomatic rejection in years 2 to 3 from previously reported 2.5% to 8.5% resulted in the biopsy every 6 months for year 2 strategy gaining 0.0006 quality-adjusted life-years, but cost $4 913 599 per quality-adjusted life-year gained. EMB for 12 months was also no longer dominant when mortality risk from untreated asymptomatic rejection approached 11%; competing strategies still cost >$200 000 per quality-adjusted life-year as that risk approached 99%.
  
  
  CONCLUSIONS
  Surveillance EMB for 12 months post-HT is more effective and less costly than EMB performed after 12 months, unless risks of asymptomatic cellular rejection and its mortality are strikingly higher than previously observed.
authors.affiliation: From the Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus (B.C.L.); Heart and Vascular Institute (J.J.T., J.H.), Pharmacy and Therapeutics (M.A.S.), and Division of General Internal Medicine (K.J.S.), University of Pittsburgh, PA. Brent.Lampert@osumc.edu.
authors.forename: Brent C
authors.initials: BC
authors.lastname: Lampert
authors.affiliation: From the Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus (B.C.L.); Heart and Vascular Institute (J.J.T., J.H.), Pharmacy and Therapeutics (M.A.S.), and Division of General Internal Medicine (K.J.S.), University of Pittsburgh, PA.
authors.forename: Jeffrey J
authors.initials: JJ
authors.lastname: Teuteberg
authors.affiliation: From the Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus (B.C.L.); Heart and Vascular Institute (J.J.T., J.H.), Pharmacy and Therapeutics (M.A.S.), and Division of General Internal Medicine (K.J.S.), University of Pittsburgh, PA.
authors.forename: Michael A
authors.initials: MA
authors.lastname: Shullo
authors.affiliation: From the Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus (B.C.L.); Heart and Vascular Institute (J.J.T., J.H.), Pharmacy and Therapeutics (M.A.S.), and Division of General Internal Medicine (K.J.S.), University of Pittsburgh, PA.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Holtz
authors.affiliation: From the Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus (B.C.L.); Heart and Vascular Institute (J.J.T., J.H.), Pharmacy and Therapeutics (M.A.S.), and Division of General Internal Medicine (K.J.S.), University of Pittsburgh, PA.
authors.forename: Kenneth J
authors.initials: KJ
authors.lastname: Smith
mesh_terms: D001706:Biopsy / Q000191:economics*; D003362:Cost-Benefit Analysis; D003955:Diagnostic Tests, Routine / Q000191:economics*; D005500:Follow-Up Studies; D006084:Graft Rejection / Q000175:diagnosis* / Q000401:mortality; D016027:Heart Transplantation; D006801:Humans; D008390:Markov Chains; D018803:Models, Economic; D009206:Myocardium / Q000473:pathology*; D011184:Postoperative Period; D012189:Retrospective Studies; D015996:Survival Rate / Q000639:trends; D013997:Time Factors; D014481:United States / Q000453:epidemiology
keywords: biopsy; cost-benefit analysis; heart transplantation