Cost Effectiveness of Using Hepatitis C Virus (HCV)-Viremic Hearts for Transplantation into HCV-Negative Recipients

Abstract

Purpose Direct acting antiviral (DAA) therapy has revolutionized the treatment of hepatitis C virus (HCV) infection with cure rates approaching 95-100%. There are recent reports of excellent outcomes following heart transplantation (HT) using HCV-viremic organs. Our aim was to assess the cost-effectiveness of using HCV-viremic hearts for transplantation into HCV-negative recipients with preemptive DAA therapy. Methods We developed a Markov model of disease progression among HCV-negative patients on the HT waitlist. We compared the cost-effectiveness between cohorts of patients willing to accept HCV-viremic or HCV-negative hearts and those only willing to accept HCV-negative hearts from a health care payer perspective with a lifetime time horizon. We examine cost-effectiveness for separate cohorts of waitlisted individuals on inotrope-dependent therapy (IDT) and with ventricular assist devices (VAD), incorporating transitions from IDT to VAD. We assumed 4.9% HCV-viremic prevalence among organ donors based on United Network for Organ Sharing (UNOS) data. We assumed all patients who received HCV-viremic hearts were treated with 12 weeks of DAAs with 95% primary and retreatment cure rates. Costs (in 2018 USD$) and health utilities (in quality-adjusted life-years) were attached to each stage and discounted 3%/year. Incremental cost-effectiveness ratios (difference in costs divided by the difference in QALYs) were calculated and considered cost-effective if falling below a $100,000 per QALY gained threshold. Results For both patient cohorts (VAD or IDT awaiting HT), accepting any heart (HCV-viremic or HCV-negative) was cost-saving compared to waiting for only HCV-negative hearts. For patients with a VAD awaiting HT, accepting any heart (HCV-viremic or HCV-negative) resulted in an increase in 0.1 QALY per patient, with an incremental cost of $-1151 compared to waiting for only HCV-negative hearts. For patients on IDT awaiting HT, accepting any heart (HCV-viremic or HCV-negative) was highly cost-saving (incremental costs $-32,971) due to averting potential costs of the VAD index hospitalization. Conclusion The use of HCV-viremic hearts for HCV-negative recipients is potentially cost-saving, and can improve clinical outcomes.