Cost-Effectiveness of Left Ventricular Assist Devices As Destination Therapy: An Economic Modelling Study

OBJECTIVES: In the UK, Left Ventricular Assist Devices (LVADs) are not commissioned by the NHS as destination therapy (advanced heart failure patients who are ineligible for heart transplantation). Existing economic evaluations of LVADs for these patients have limitations. This study aimed to estimate the cost-effectiveness of LVADs as destination therapy in the UK compared to optimal medical therapy.

METHODS: A cost-utility analysis from an NHS perspective was conducted, using a novel Markov model with a lifetime horizon and monthly cycles. The model development was informed by systematic reviews and guidance from clinicians, patients and commissioners. The costs were in UK£ at 2019 prices, and a discount rate of 3.5% was employed. The analysis was repeated incorporating the probability of transition to heart transplant (HT). Exploratory sub-group analyses estimated the impact of severity of heart failure (INTERMACS profiles) on cost-effectiveness. Uncertainty was measured in deterministic and probabilistic sensitivity analyses.

RESULTS: LVAD produced an additional 2.20 (95% CI 1.99 – 2.42) QALYs at an incremental cost of £140,375 (95% CI £116,889 - £166,018) compared to medical management. Thus, the incremental cost-effectiveness ratio per QALY (ICER) was £63,870. The probability of cost-effectiveness was 2% at a threshold of £50,000 per QALY gained, reaching 100% at a threshold of £90,000. The ICER remained above £50,000 if a small proportion of patients receiving LVAD become eligible for a heart transplant and in sub-group analyses based on INTERMACS profiles. The deterministic sensitivity analysis revealed that varying the ongoing outpatient costs for medical management had a significant impact on the results.

CONCLUSIONS: In contrast to two recent UK studies, this study found that LVADs are not cost-effective as destination therapy in the UK at a threshold of £50,000 per QALY gained. Robust data on ongoing costs for medical management are needed.