University of Twente Student Theses

Cost-effectiveness analysis of LVADs as destination therapy compared to bridge-to-transplantation or heart transplantation for end-stage heart failure patients in the Netherlands

Hoefnagel, Femke (2025) Cost-effectiveness analysis of LVADs as destination therapy compared to bridge-to-transplantation or heart transplantation for end-stage heart failure patients in the Netherlands.

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Abstract:	Introduction: Heart failure (HF) is a major public health problem, affecting nearly two percent of the Dutch population, with end-stage heart failure (ESHF) being a critical form of the disease. ESHF patients experience severe symptoms despite optimal medical treatment, often resulting in a reduced quality of life. While heart transplantation (HTx) is the preferred treatment, long waiting times and limited donor availability create significant challenges. Left Ventricular Assist Devices (LVADs) have become a valuable alternative, initially used as a bridge to transplantation (BTT), but increasingly used as destination therapy (DT) for patients who are ineligible for a transplant. However, the high cost of LVADs raises questions about their cost-effectiveness. This study aims to assess the cost-effectiveness of LVADs as DT compared to BTT and HTx for ESHF patients in the Netherlands. Methods: This study is a model-based cost-effectiveness analysis (CEA) comparing LVAD as DT to usual care, which is a Combined strategy of LVAD as BTT and HTx, in the context of Dutch healthcare. A cohort Markov model was developed with health states: pharmaceutical management (PM), LVAD as BTT, LVAD as DT, HTx, and death. Transition probabilities, costs, and utilities were used as input for the model. The cohort consists of ESHF patients on the transplant waiting list, and the model simulates transitions over a lifetime horizon with starting age 40, with monthly cycles. Several strategies were evaluated, including LVAD as DT, LVAD as BTT, HTx, and a Combined strategy, to assess the cost-effectiveness of LVAD as DT compared to other options. Extrapolated survival curves, fitted using the Weibull distribution, were developed based on Kaplan-Meier (KM) curves to model the transitions to death. A probabilistic sensitivity analysis (PSA), one-way sensitivity analysis (OWSA) and scenario analyses were performed to assess the impact of uncertainty on results. Results: In the deterministic model, the HTx and Combined strategies were more cost-effective than the LVAD as DT strategy. LVAD as BTT was dominated by HTx and the Combined strategy. Although LVAD as DT has low costs, it is associated with low quality adjusted life-years (QALYs), making the other strategies more favorable. PSA results confirmed the robustness of the model. OWSA showed that transition probabilities for PM to LVAD as BTT or HTx, costs of LVAD as BTT and HTx, and utility of HTx have the greatest impact on the model. One scenario analysis showed decreased costs and QALYs for health states including HTx, when the model takes into account the limited availability of heart donors. Another scenario analysis showed slightly better cost-effectiveness for the LVAD strategies when the cost of the device decreased. Conclusion: This CEA found that LVAD as DT is not cost-effective compared to usual care for ESHF patients in the Netherlands, as its lower costs are balanced by lower QALYs. The lower survival rate of LVAD as DT and limited patient eligibility contribute to its lack of cost-effectiveness. While reducing LVAD device costs or limiting heart transplants could help, improvements in survival and quality of life are needed for LVAD as DT to become cost-effective.
Item Type:	Essay (Master)
Faculty:	TNW: Science and Technology
Subject:	44 medicine, 83 economics
Programme:	Health Sciences MSc (66851)
Link to this item:	https://purl.utwente.nl/essays/105355
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