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Bosch L, Zwetsloot PPM, Brons M, van Hout GPJ, van der Meer MG, Szymanski MK, Troost-Oppelaar AM, Ramjankhan FZ, van der Harst P, Gianoli M, Oerlemans MIFJ, van Laake LW. Healthcare consumption of patients with left ventricular assist device: real-world data. Neth Heart J 2024:10.1007/s12471-024-01885-5. [PMID: 39141306 DOI: 10.1007/s12471-024-01885-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2024] [Indexed: 08/15/2024] Open
Abstract
BACKGROUND A left ventricular assist device (LVAD) is a life-saving but intensive therapy for patients with end-stage heart failure. We evaluated the healthcare consumption in a cohort of LVAD patients in our centre over 6 years. METHODS All patients with a primary LVAD implantation at the University Medical Centre Utrecht in Utrecht, the Netherlands from 2016 through 2021 were included in this analysis. Subsequent hospital stay, outpatient clinic visits, emergency department visits and readmissions were recorded. RESULTS During the investigated period, 226 LVADs were implanted, ranging from 32 in 2016 to 45 in 2020. Most LVADs were implanted in patients aged 40-60 years, while they were supported by or sliding on inotropes (Interagency Registry for Mechanically Assisted Circulatory Support class 2 or 3). Around the time of LVAD implantation, the median total hospital stay was 41 days. As the size of the LVAD cohort increased over time, the total annual number of outpatient clinic visits also increased, from 124 in 2016 to 812 in 2021 (p = 0.003). The numbers of emergency department visits and readmissions significantly increased in the 6‑year period as well, with a total number of 553 emergency department visits and 614 readmissions. Over the years, the annual number of outpatient clinic visits decreased by 1 per patient-year follow-up, while the annual numbers of emergency department visits and readmissions per patient-year remained stable. CONCLUSION The number of patients supported by an LVAD has grown steadily over the last years, requiring a more specialised healthcare in this particular population.
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Affiliation(s)
- Lena Bosch
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | | | - Maaike Brons
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Gerardus P J van Hout
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Manon G van der Meer
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
- Transplantation Centre, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Mariusz K Szymanski
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
- Transplantation Centre, University Medical Centre Utrecht, Utrecht, The Netherlands
| | | | - Faiz Z Ramjankhan
- Department of Cardiothoracic Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Pim van der Harst
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Monica Gianoli
- Department of Cardiothoracic Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Marish I F J Oerlemans
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
- Transplantation Centre, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Linda W van Laake
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands.
- Transplantation Centre, University Medical Centre Utrecht, Utrecht, The Netherlands.
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Abstract
Heart failure is a progressive condition that continues to increase in both incidence and prevalence despite pharmacologic treatment. The high rate of morbidity and mortality associated with advanced heart failure has led to exploration of additional treatments, which include surgical interventions to improve outcomes. Heart transplant remains the gold standard but, because of the persistent donor shortage and increasing number of patients with advanced heart failure, mechanical circulatory support is gaining acceptance and can be used as a bridge to heart transplant for those eligible or as destination therapy.
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Affiliation(s)
- Candice Falls
- Internal Medicine-Cardiology, University of Kentucky, 1000 South Limestone Pavilion A 08.176, Lexington, KY, USA.
| | - Andrew R Kolodziej
- Gill Heart Institute, University of Kentucky, 900 South Limestone, CTW 320, Lexington, KY 40536, USA
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Kwon R, Allen LA, Scherer LD, Thompson JS, Abdel-Maksoud MF, McIlvennan CK, Matlock DD. The Effect of Total Cost Information on Consumer Treatment Decisions: An Experimental Survey. Med Decis Making 2019; 38:584-592. [PMID: 29847252 DOI: 10.1177/0272989x18773718] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Unrestrained use of expensive, high-risk interventions runs counter to the idea of a limited medical commons. OBJECTIVE To examine the effect of displaying the total first-year cost of implanting a left ventricular assist device (LVAD) on a hypothetical treatment decision and whether this effect differs when choosing for oneself versus for another person. DESIGN We conducted an online survey in February 2016. The survey described the clinical course of end-stage heart failure and the risks and benefits of an LVAD. Participants were randomized to 1 of 4 scenarios, which varied by patient identity (oneself versus another person) and description of total cost. MEASUREMENTS This study measured acceptance of LVAD implantation. Reasoning and attitudes were secondarily explored. RESULTS We received 1211 valid responses. The mean age was 38.3 y (±12.8); 53.5% were female and 84.4% were white. Participants were more likely to accept an LVAD when shown the total cost (66.2% v. 58.0%, P = 0.003) or when choosing for another (68.0 % v. 56.4%, P < 0.001). Open-ended responses indicated that acceptors wanted to extend survival while decliners feared poor quality of life with LVAD therapy. Acceptors and decliners agreed that consumers can help lower the cost of health care, but decliners were more likely to consider cost when making health care decisions ( P < 0.001). LIMITATIONS Limitations include the use of a hypothetical scenario, the use of paid participants, and differences between the respondents and the typical patient facing an LVAD decision. CONCLUSIONS In this sample, being shown the total cost increased the likelihood of accepting an expensive, high-risk treatment. The results question how well consumers understand the relationship between expensive treatments and the commons.
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Affiliation(s)
- Regina Kwon
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Larry A Allen
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA.,Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA
| | - Laura D Scherer
- Department of Psychological Sciences, University of Missouri, Columbia, MO, USA
| | - Jocelyn S Thompson
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Colleen K McIlvennan
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA.,Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA
| | - Daniel D Matlock
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA.,Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA.,VA Eastern Colorado Geriatrics Research, Education, and Clinical Center, Denver, CO, USA
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Abstract
BACKGROUND Despite significant changes in the past decade for children undergoing heart transplantation, including the evolution of mechanical circulatory support and increasing patient complexity, costs and resource utilization have not been reassessed. We sought to use a novel linkage of clinical-registry and administrative data to examine changes in hospitalization costs over time in this population. METHODS We identified all pediatric heart transplant recipients in a unique linked Pediatric Health Information System/Scientific Registry of Transplant Recipients data set (2002-2016). Hospital costs were estimated from charges using cost-to-charge ratios, inflated to 2016 dollars. Severity-adjusted costs were calculated using generalized linear mixed-effects models. Costs were compared across 3 eras (era 1, 2002-2006; era 2, 2007-2011; and era 3, 2012-2016). RESULTS A total of 2896 pediatric heart transplant recipients were included: era 1, 649 (22.4%); era 2, 1028 (35.5%); and era 3, 1219 (42.1%). Extracorporeal membrane oxygenation support at transplant decreased over time, concurrent with an increase in ventricular assist device-supported patients. Between era 1 and era 2, there was an increase in pretransplant hospitalization costs (US $343 692 vs US $435 554; P < 0.001). However, between era 2 and era 3, there was a decline in total (US $906 454 vs US $767 221; P < 0.001), pretransplant (US $435 554 vs US $353 364; P < 0.001), and posttransplant (US $586 133 vs US $508 719; P = 0.002) hospitalization costs. CONCLUSIONS Concurrent with the increase in utilization of ventricular assist device support, there has been an increase in pretransplant costs associated with pediatric heart transplantation. However, in the most recent era, costs have declined. These findings suggest the evolution of more cost-effective management strategies, which may be related to shifts in the approach to pediatric mechanical circulatory support.
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Magnetta DA, Kang J, Wearden PD, Smith KJ, Feingold B. Cost-Effectiveness of Ventricular Assist Device Destination Therapy for Advanced Heart Failure in Duchenne Muscular Dystrophy. Pediatr Cardiol 2018; 39:1242-1248. [PMID: 29774392 DOI: 10.1007/s00246-018-1889-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 05/02/2018] [Indexed: 11/28/2022]
Abstract
Destination ventricular assist device therapy (DT-VAD) is well accepted in select adults with medically refractory heart failure (HF) who are not transplant candidates; however, its use in younger patients with progressive diseases is unclear. We sought to evaluate the cost-effectiveness of DT-VAD in Duchenne muscular dystrophy (DMD) patients with advanced HF. We created a Markov-state transition model (5-year horizon) to compare survival, costs, and quality of life (QOL) between medical management and DT-VAD in DMD with advanced HF. Model input parameters were derived from the literature. We used sensitivity analyses to explore uncertainty around model assumptions. DT-VAD had higher costs ($435,602 vs. $125,696), survival (3.13 vs. 0.60 years), and quality-adjusted survival (1.99 vs. 0.26 years) than medical management. The incremental cost-effectiveness ratio (ICER) for DT-VAD was $179,086 per quality-adjusted life year (QALY). In sensitivity analyses that were widely varied to account for uncertainty in model assumptions, the DT-VAD strategy generally remained more costly and effective than medical management. Only when VAD implantation costs were <$113,142 did the DT-VAD strategy fall below the $100,000/QALY willingness-to-pay threshold commonly considered to be "cost-effective." In this exploratory analysis, DT-VAD for patients with DMD and advanced HF exceeded societal expectations for cost-effectiveness but had an ICER similar to the accepted practice of DT-VAD in adult HF patients. While more experience and research in this population is needed, our analysis suggests that DT-VAD for advanced HF in DMD should not be dismissed solely based on cost.
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Affiliation(s)
- Defne A Magnetta
- Pediatrics, Children's Hospital of Pittsburgh, 4401 Penn Avenue, Faculty Pavilion Floor 5, Pittsburgh, PA, 15224, USA.
| | - JaHyun Kang
- College of Nursing, Seoul National University, Seoul, South Korea.,Research Institute of Nursing Science, Seoul National University, Seoul, South Korea
| | - Peter D Wearden
- Cardiothoracic Surgery, Nemours Children's Hospital, Orlando, FL, USA
| | - Kenneth J Smith
- Section of Decision Sciences, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Brian Feingold
- Pediatrics, Children's Hospital of Pittsburgh, 4401 Penn Avenue, Faculty Pavilion Floor 5, Pittsburgh, PA, 15224, USA.,Clinical and Translational Research, University of Pittsburgh, Pittsburgh, PA, USA
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The In-Hospital Cost of Ventricular Assist Device Therapy: Implications for Patient Selection. ASAIO J 2018; 63:725-730. [PMID: 28195882 DOI: 10.1097/mat.0000000000000545] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Ventricular assist device (VAD) therapy is increasingly utilized to support patients in end-stage heart failure. However, VAD programs are resource intensive and demand active monitoring to ensure long-term sustainability. The purpose of this study was to analyze total cost trends of the VAD program at our academic medical center. Retrospective analysis of University of California - Los Angeles's VAD program between 2013 and 2014 was performed. Total in-hospital costs from the date of VAD surgery admission were queried and normalized to a z score. Multivariable linear regression analysis with step-wise elimination was used to model total costs. Overall, 42 patients received a VAD during the study period, with 19 (45%) receiving biventricular support. On univariate analysis, high body mass index, biventricular support, time between VAD implantation and discharge, and total length of hospital stay were correlated with higher costs (all p < 0.02). On multivariable analysis, time between VAD implantation and discharge and biventricular support remained significantly related to total costs (overall R = 0.831, p < 0.001). The time between VAD implantation and discharge and the use of biventricular support were the most predictive factors of total cost in our VAD population. Reducing hospital stay post-VAD implantation is important in minimizing the cost of VAD care.
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Tadmouri A, Blomkvist J, Landais C, Seymour J, Azmoun A. Cost-effectiveness of left ventricular assist devices for patients with end-stage heart failure: analysis of the French hospital discharge database. ESC Heart Fail 2017; 5:75-86. [PMID: 28741873 PMCID: PMC5793974 DOI: 10.1002/ehf2.12194] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 04/25/2017] [Accepted: 06/20/2017] [Indexed: 01/20/2023] Open
Abstract
AIMS Although left ventricular assist devices (LVADs) are currently approved for coverage and reimbursement in France, no French cost-effectiveness (CE) data are available to support this decision. This study aimed at estimating the CE of LVAD compared with medical management in the French health system. METHODS AND RESULTS Individual patient data from the 'French hospital discharge database' (Medicalization of information systems program) were analysed using Kaplan-Meier method. Outcomes were time to death, time to heart transplantation (HTx), and time to death after HTx. A micro-costing method was used to calculate the monthly costs extracted from the Program for the Medicalization of Information Systems. A multistate Markov monthly cycle model was developed to assess CE. The analysis over a lifetime horizon was performed from the perspective of the French healthcare payer; discount rates were 4%. Probabilistic and deterministic sensitivity analyses were performed. Outcomes were quality-adjusted life years (QALYs) and incremental CE ratio (ICER). Mean QALY for an LVAD patient was 1.5 at a lifetime cost of €190 739, delivering a probabilistic ICER of €125 580/QALY [95% confidence interval: 105 587 to 150 314]. The sensitivity analysis showed that the ICER was mainly sensitive to two factors: (i) the high acquisition cost of the device and (ii) the device performance in terms of patient survival. CONCLUSIONS Our economic evaluation showed that the use of LVAD in patients with end-stage heart failure yields greater benefit in terms of survival than medical management at an extra lifetime cost exceeding the €100 000/QALY. Technological advances and device costs reduction shall hence lead to an improvement in overall CE.
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Affiliation(s)
- Abir Tadmouri
- Health Economics and Outcome Research (HEOR) Department, ClinSearch, Malakoff, France
| | - Josefin Blomkvist
- Health Economics and Outcome Research (HEOR) Department, ClinSearch, Malakoff, France
| | - Cécile Landais
- Health Economics and Outcome Research (HEOR) Department, ClinSearch, Malakoff, France
| | - Jerome Seymour
- Health Economics and Outcome Research (HEOR) Department, ClinSearch, Malakoff, France
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Vanden Eynden F, Antoine M, El Oumeiri B, Chirade ML, Vachiéry JL, Van Nooten GJ. How to cope with a temporarily aborted transplant program: solutions for a prolonged waiting period. ANNALS OF TRANSLATIONAL MEDICINE 2015; 3:306. [PMID: 26697466 DOI: 10.3978/j.issn.2305-5839.2015.11.30] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Due to budgetary restrictions our university heart transplant program came to a standstill to be gradually restarted early 2011. Consequently waiting-times for transplantation increased dramatically beyond the usual 10-15 months. We reviewed the clinical results of this peculiar transplant program over the past 4 years. METHODS Since March 2011 until February 2015, 65 patients (age 48±23 years) were listed for heart transplantation. Eight patients (11%) of whom three in high emergency were transplanted without any form of mechanical assistance. Fifty-one patients required a left ventricular assist device (LVAD) Heartware (Heartware Inc., Miami Lakes, FL, USA) as a bridge-to-transplant due to terminal heart failure. Merely 5 listed patients remain without assistance. RESULTS One patient without assistance and 11 LVAD patients (22%) died on the waiting-list. Meanwhile 10 LVAD patients were transplanted after a 2-year waiting time (770±717 days). Four transplanted patients died of early graft failure none after LVAD explantation. Survival at 1 and 3 years was respectively 78 (72%) and 83 (78%) for transplanted and assisted patients (log-rank P=0.056). Cox multivariable regression analysis identified crash-to-burn patients (P=0.002) and waiting-times over 2 years (P=0.044) as risk factors for early death, while age above 60 (P=0.008) and ischemic aetiology (P=0.029) and pulmonary hypertension (P=0.092) were risk factors for survival. CONCLUSIONS In times of donor shortage mechanical assistance proves very effective as bridge-to-transplant in patients for whom candidacy follows the standard inclusion procedures. In our settings, a steep increase in LVAD implantation served to salvage patients for whom transplantation became jeopardized due to an ever increasing waiting-time. Circulatory LVAD support could be considered as primary therapy in the future.
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Affiliation(s)
- Frédéric Vanden Eynden
- 1 Department of Cardiac Surgery, University Hospital Erasme ULB, Brussels, Belgium ; 2 Faculty of Medicine, University of Ghent, Ghent, Belgium
| | - Martine Antoine
- 1 Department of Cardiac Surgery, University Hospital Erasme ULB, Brussels, Belgium ; 2 Faculty of Medicine, University of Ghent, Ghent, Belgium
| | - Bachar El Oumeiri
- 1 Department of Cardiac Surgery, University Hospital Erasme ULB, Brussels, Belgium ; 2 Faculty of Medicine, University of Ghent, Ghent, Belgium
| | - Marie-Luce Chirade
- 1 Department of Cardiac Surgery, University Hospital Erasme ULB, Brussels, Belgium ; 2 Faculty of Medicine, University of Ghent, Ghent, Belgium
| | - Jean-Luc Vachiéry
- 1 Department of Cardiac Surgery, University Hospital Erasme ULB, Brussels, Belgium ; 2 Faculty of Medicine, University of Ghent, Ghent, Belgium
| | - Guido J Van Nooten
- 1 Department of Cardiac Surgery, University Hospital Erasme ULB, Brussels, Belgium ; 2 Faculty of Medicine, University of Ghent, Ghent, Belgium
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Droogne W, Jacobs S, Van den Bossche K, Verhoeven J, Bostic RR, Vanhaecke J, Van Cleemput J, Rega F, Meyns B. Cost of 1-year left ventricular assist device destination therapy in chronic heart failure: a comparison with heart transplantation. Acta Clin Belg 2014; 69:165-70. [PMID: 24820923 DOI: 10.1179/2295333714y.0000000017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVE To analyse overall cost involved with destination therapy (DT) in comparison to transplantation (HTX) and bridging to transplantation. METHODS Three groups of patients at one hospital were considered for this cost analysis: (1) patients included in the BENEMACS study starting May 2009 (n = 6); (2) all patients from May 2009 till May 2010 undergoing heart transplantation (n = 19); or (iii) undergoing Heartmate II implantation as a bridge to transplant (n = 13). Patients undergoing bridging were more sick (lower Intermacs class). DT patients were older (64±8 years). Cost was derived from actual hospital invoices, device, organ procurement and medical cost, and follow-up care during 1 year from implantation. Costs are presented in euro, by their mean values and standard deviation. RESULTS One-year survivals were 83, 84, and 77%, respectively, for DT, HTX, and bridging. Costs for initial and re-hospitalizations were not different between groups. Costs for medical follow-up and medication were significantly higher for transplanted patients. The 1-year total cost was €85 531±19 823 for HTX, €125 108±32 399 for bridging, and €137 068±29 007 for DT. As 42% of the transplanted patients were bridged, the cost of the medical pathway HTX was €138 076±19 823. Assuming a 5-year survival and a similar yearly follow-up cost, the average cost per year is €42 153 for HTX, €53 637 for transplantation including the bridging cost, and €47 487 for DT. CONCLUSION Direct transplantation without bridging is the most cost-efficient treatment. The cost per patient per year for DT is similar to HTX considering its bridging activity.
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Compostella L, Russo N, Setzu T, Compostella C, Bellotto F. Exercise performance of chronic heart failure patients in the early period of support by an axial-flow left ventricular assist device as destination therapy. Artif Organs 2013; 38:366-73. [PMID: 24117945 DOI: 10.1111/aor.12172] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Axial-flow left ventricular assist devices (LVADs) are increasingly used as destination therapy in end-stage chronic heart failure (CHF), as they improve survival and quality of life. Their effect on exercise tolerance in the early phase after implantation is still unclear. The aim of this study was to evaluate the effect of LVADs on the exercise capacity of a group of CHF patients within 2 months after initiation of circulatory support. Cardiopulmonary exercise test data were collected for 26 consecutive LVAD-implanted CHF patients within 2 months of initiation of assistance; the reference group consisted of 30 CHF patients not supported by LVAD who were evaluated after an episode of acute heart failure. Both LVAD and reference groups showed poor physical performance; LVAD patients achieved lower workload (LVAD: 36.3 ± 9.0 W, reference: 56.6 ± 18.2 W, P < 0.001) but reached a similar peak oxygen uptake (peak VO2 ; LVAD: 12.5 ± 3.0 mL/kg/min, reference: 13.6 ± 2.9 mL/kg/min, P = ns) and similar percentages of predicted peak VO2 (LVAD: 48.8 ± 13.9%, reference: 54.2 ± 15.3%, P = ns). While the values of the O2 uptake efficiency slope were 12% poorer in LVAD patients than in reference patients (1124.2 ± 226.3 vs. 1280.2 ± 391.1; P = ns), the kinetics of VO2 recovery after exercise were slightly better in LVAD patients (LVAD: 212.5 ± 62.5, reference: 261.1 ± 80.2 sec, P < 0.05). In the first 2 months after initiation of circulatory support, axial-flow LVAD patients are able to sustain a low-intensity workload; though some cardiopulmonary exercise test parameters suggest persistence of a marked physical deconditioning, their cardiorespiratory performance is similar to that of less compromised CHF patients, possibly due to positive hemodynamic effects beginning to be produced by the assist device.
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Affiliation(s)
- Leonida Compostella
- Preventive Cardiology and Rehabilitation, Istituto Codivilla Putti, Cortina d'Ampezzo
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