title: Cost-effectiveness of pediatric heart transplantation across a positive crossmatch for high waitlist urgency candidates.
abstract: Allosensitized children listed with a requirement for a negative prospective crossmatch have high mortality. Previously, we found that listing with the intent to accept the first suitable organ offer, regardless of the possibility of a positive crossmatch (TAKE strategy), results in a survival advantage from the time of listing compared to awaiting transplantation across a negative crossmatch (WAIT). The cost-effectiveness of these strategies is unknown. We used Markov modeling to compare cost-effectiveness between these waitlist strategies for allosensitized children listed urgently for heart transplantation. We used registry data to estimate costs and waitlist/posttransplant outcomes. We assumed patients remained in hospital after listing, no positive crossmatches for WAIT, and a base-case probability of a positive crossmatch of 47% for TAKE. Accepting the first suitable organ offer cost less ($405 904 vs. $534 035) and gained more quality-adjusted life years (3.71 vs. 2.79). In sensitivity analyses, including substitution of waitlist data from children with unacceptable antigens specified during listing, TAKE remained cost-saving or cost-effective. Our findings suggest acceptance of the first suitable organ offer for urgently listed allosensitized pediatric heart transplant candidates is cost-effective and transplantation should not be denied because of allosensitization status alone.
authors.affiliation: Pediatric Cardiology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA.|Clinical and Translational Science, University of Pittsburgh, Pittsburgh, PA.
authors.forename: B
authors.initials: B
authors.lastname: Feingold
authors.affiliation: Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN.
authors.forename: S A
authors.initials: SA
authors.lastname: Webber
authors.affiliation: Health Policy Management, University of Pittsburgh School of Public Health. Pittsburgh, PA.
authors.forename: C L
authors.initials: CL
authors.lastname: Bryce
authors.affiliation: Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.
authors.forename: S Y
authors.initials: SY
authors.lastname: Park
authors.affiliation: Health Policy Management, University of Pittsburgh School of Public Health. Pittsburgh, PA.
authors.forename: H E
authors.initials: HE
authors.lastname: Tomko
authors.affiliation: Pediatric Cardiology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA.
authors.forename: S C
authors.initials: SC
authors.lastname: West
authors.affiliation: Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA.
authors.forename: S A
authors.initials: SA
authors.lastname: Hart
authors.affiliation: Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA.
authors.forename: W T
authors.initials: WT
authors.lastname: Mahle
authors.affiliation: Section of Decision Sciences and Clinical Systems Modeling, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.
authors.forename: K J
authors.initials: KJ
authors.lastname: Smith
mesh_terms: D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D017046:Cost Savings; D003362:Cost-Benefit Analysis; D016208:Databases, Factual; D004630:Emergencies; D005260:Female; D006084:Graft Rejection; D006085:Graft Survival; D016027:Heart Transplantation / Q000009:adverse effects / Q000191:economics* / Q000379:methods*; D006650:Histocompatibility Testing / Q000191:economics* / Q000379:methods; D017721:Hospital Costs; D006801:Humans; D007223:Infant; D008297:Male; D008390:Markov Chains; D018579:Patient Selection; D010372:Pediatrics; D011379:Prognosis; D012042:Registries; D018570:Risk Assessment; D012680:Sensitivity and Specificity; D013997:Time Factors; D016896:Treatment Outcome; D014850:Waiting Lists
keywords: alloantibody; crossmatch; organ allocation; quality of life (QOL); waitlist management