Economic Evaluation of Left Ventricular Assist Devices for Patients With End Stage Heart Failure Who Are Ineligible for Cardiac Transplantation

Background: Continuous flow (CF) left ventricular assist devices (LVADs) improve survival in end-stage heart failure patients who are ineligible for cardiac transplantation. Their use in this population ( referred to as destination therapy) is increasing in many countries, yet they are not routinely funded for this indication in Canada. We assessed the cost-effectiveness of destination therapy CF-LVADs from the perspective of the Canadian health care payer. Methods: A Markov model was used to project the outcomes and costs of 2 treatment pathways, CF-LVAD implantation and medical management alone, in an end-stage heart failure patient cohort ineligible for transplantation. Clinical and cost input estimates were informed from the available literature. Model outcomes included costs (in 2015 Canadian dollars), quality-adjusted life-years (QALYs), and the cost per QALY gained. Results: Compared with medical management, CF-LVAD patients had higher costs ($284,287 vs $31,984) and QALYs (1.48 vs 0.39) over a lifetime horizon. The incremental cost per QALY gained was $230,692. The model was most sensitive to device implantation costs, and the clinical effectiveness of CF-LVADs on survival and quality of life. A scenario analysis using contemporary survival data resulted in a cost per QALY gained of $125,936. When applying contemporary LVAD survival trends, the model showed that the cost of initial LVAD implantation needed to be less than $123,000 to be considered costeffective. Conclusions: The incremental cost per QALY for destination therapy CF-LVADs is predicted to be above usual thresholds for funding in Canada. In some plausible scenarios, its cost-effectiveness is similar to dialysis for kidney failure, a therapy that is also immediately lifesaving. Because of this, there will be likely ongoing pressure to fund CF-LVADs for a subset of patients ineligible for transplantation.