Cost-Effectiveness of a Small Intrapericardial Centrifugal LVAD versus Medical Management in Destination Therapy Patients in the UK

Abstract

Continuous-flow Left Ventricular Assist Devices (LVADs) as destination therapy (DT) are a recommended treatment by NICE England for end stage heart failure patients ineligible for heart transplantation. While DT is frequently used as an LVAD indication across other major European countries and in the US with consistent improvements in quality-of-life and longevity, NHS England does not fund DT mainly due to cost-effectiveness concerns. Based on the recently published ENDURANCE Supplemental trial studying DT patients, we assessed for the first time the cost-effectiveness of LVADs in the DT indication compared to medical management in the NHS England. We built a Markov multiple-state economic model using NHS cost data. Clinical inputs were based on LVAD trial data. Survival and adverse event rates were taken from the contemporary ENDURANCE Supplemental trial for the LVAD arm. Survival for the medical management arm was based on the Seattle Heart Failure Model estimates in the absence of contemporary clinical trials for this population. Incremental cost-effectiveness ratios (ICERs) were calculated over a life time horizon. We conducted various sensitivity analyses. A discount rate of 3 % per year was applied to costs and benefits. The ICER of the small intrapericardial centrifugal LVAD per quality-adjusted life year (QALY) gained was £45,618 and £34,375 per life-year gained (LY). Costs and utilities were £209,241 and 3.42 QALYs for the LVAD arm versus £78,196 and 0.54 QALYs for the medical management arm. Sensitivity analyses showed robust results. The implantation of a small intrapericardial centrifugal LVAD in patients with the DT indication who are not eligible for heart transplantation is a cost-effective therapy in the NHS England healthcare system under the willingness-to-pay threshold of £50,000 per QALY, which applies for end-of life care.