Objectives: Increased numbers of end-stage heart failure patients and improved technology have led to increased use of left ventricular assist devices as a viable alternative to heart transplants. Given the current economic climate, we compared costs of heart transplant versus device placement.

Materials and Methods: Medical records of patients who received heart transplants or left ventricular assist devices were cross-referenced with institutional financial data. The device cohort was limited to those receiving durable (not temporary) devices. Index admission, 1-year readmission, and overall 1-year charges were compared using standard statistical methods.

Results: Of 184 identified patients with end-stage heart failure surgical therapy, 121 received left ventricular assist devices, 43 had heart transplants, and 20 received left ventricular assist devices as bridge to heart transplant; these latter patients were excluded from our analyses. At index admission, mean charges were $863 433 ± $398 427 for device patients and $725 877 ± $488 685 for transplant patients (P = .05). One-year mean readmission rates were similar (4.65/transplant patient and 4.53/device patient; P = .94), with corresponding 1-year survival rates of 87.8% and 78.0% (P = .04). Total readmission charges during year 1 were $169 732 ± $242 366 for device patients and $201 682 ± $297 565 for transplant patients (P = .08), with corresponding overall charges at 1 year of $1 029 732 ± $450 498 and $927 559 ± $562 404 (P = .49).

Conclusions: During the first year, heart transplant and left ventricular assist device placement have similar costs. Initial index admission costs seem to favor heart transplant, with device pump costs accounting for some of the difference. From a 1-year survival perspective, heart transplant may be more effective; however, with lack of suitable donors, left ventricular assist devices are valuable in the armamentarium of advanced heart failure surgical options.

Key words : Heart failure, Heart-assist device economics

Introduction

There are an estimated 5 million people diagnosed with heart failure in the United States, with over half a million new cases each year. Heart failure is on the discharge diagnosis in 1 of 8 patients hospitalized, with a cost burden of $31 billion in the United States.¹ It is projected that, by 2030, there will be 8 million Americans living with heart failure with an estimated cost of $70 billion. This population growth combined with the continued discordance that the United States spends on health care versus other developed countries has thrust the issue of cost containment in the treatment of patients with advanced end-stage heart failure to the forefront.^2,3

Despite the medical advances in the treatment of heart failure, advanced surgical therapy, via either left ventricular assist device (LVAD) implant or heart transplant, provides the best long-term outcomes for patients with inotrope-dependent and/or recurrent heart failure.⁴ Indeed, LVAD use has risen exponentially and surged to over 2500 primary implants in 2013 alone, as shown in the Interagency Registry for Mechanically Assisted Circulatory Support.⁵ Heart transplant remains the criterion standard of therapy; however, in addition to the shortage of suitable donor organs, it carries a large financial and ethical burden. The increased use of LVADs in combination with the increased longevity of life with LVAD therapy begs the question of whether LVADs are bridging the gap with heart transplant as definitive therapy for end-stage heart failure.⁶

Given the current economic emphasis on cost versus patient benefit and outcome, we aimed to compare the financial effectiveness of heart transplant versus LVAD procedures. Although there have been previous reports in the literature investigating this, all have been results of either multi-institutional collaborations with incomplete financial data or large database queries, making it difficult to fully compare these 2 therapies. In addition, there are also differences between institutions and significant hospital-to-hospital variability in both direct and indirect costs associated with these surgical procedures. As such, we chose to concentrate on the fiscal impact of LVAD usage as singular therapy and compare its cost with primary transplant alone in our own institution.

Materials and Methods

We retrospectively analyzed our prospectively maintained heart transplant and LVAD databases from July 1, 2008, to June 30, 2013. The study was approved by the institutional review board at the Ohio State University with a waiver of need for patient consent. We limited our LVAD cohort to those who received a durable (ie, not temporary) device and with first-time implant of LVAD. Patients were divided into 2 cohorts: those with LVAD destination therapy and those who received a heart transplant. Baseline patient demographics (age, sex, race) and presence of comorbidities (body mass index, presence of arrhythmia, chronic renal insufficiency [defined as glomerular filtration rate < 60 mL/min/1.73 m²], type 2 diabetes mellitus, hypertension, peripheral arterial disease, and prior cerebrovascular accident) were obtained and compared between groups. Patient medical records were cross-referenced with institutional financial data. We evaluated overall charges, payments received, direct fixed and variable costs, and LVAD pump charges. We also analyzed and compared institutional costs at index admission, all costs incurred with readmission within the first year (direct and indirect costs for index admission and each encounter), 1-year readmission rates, and 1-year survival rates.

Statistical analyses
Categorical variables are presented as absolute number and percentages, and continuous variables are presented as means ± standard deviations. Categorical variables were analyzed using the chi-squared or Fisher exact test. Continuous variables were analyzed using t test or Wilcoxon signed rank test. All statistical analyses were carried out using STATA 13.1 (StataCorp LP, College Station, TX, USA). P < .05 was considered to be statistically significant.

Results

We identified 184 patients who underwent surgical procedures for advanced heart failure. Of these, 121 solely received LVAD and 43 solely had heart transplant procedures, with 20 patients excluded because they were bridged with an LVAD to heart transplant. The baseline characteristics of patients are summarized in Table 1. The 2 groups were similar regarding age, sex, body mass index, presence of chronic renal insufficiency, presence of arrhythmias, history of cerebrovascular accident, and peripheral arterial disease. The heart transplant group had a higher rate of type 2 diabetes mellitus (55.8%) compared with the LVAD group (38.0%; P = .03). In addition, a greater percentage of patients had a history of hypertension (83.7% vs 43.8%; P < .01) in the heart transplant group than in the LVAD group.

In assessing index admission, the mean total charges were $863 433 ± $398 427 for LVAD and $725 877 ± $488 685 for heart transplant procedures (P = .05). Incurred costs were separated into total direct fixed, indirect fixed, direct variable, and indirect variable costs, with each of these and their totals analyzed (Table 2). The total direct and indirect fixed costs strongly trended toward a higher cost for heart transplant; however, these did not reach statistical significance (P = .08 and P = .07). The variable cost breakdown, on the other hand, showed an increase in direct variable costs for LVADs versus heart transplants ($172 338 ± $60 386 vs $108 667 ± $69 003; P < .01). Indirect variable costs were similar for LVAD ($7712 ± $4035) and heart transplant ($7948 ± $4915; P = .94). When all total direct costs and indirect costs were combined, there was an increased direct cost for LVADs ($195 039 ± $105 232) vs heart transplant ($144 229 ± $79 799; P < .01). Conversely, there was an increased indirect cost associated with heart transplant ($92 900 ± $41 203) vs LVADs ($64 847 ± $34 665; P = .03) during the index admission. The total costs, however, showed equivalency between the 2 groups, with LVAD cost being $258 726 ± $105 232 and heart transplant cost being $237 129 ± $118 762 (P = .21).

In the first year, there were similar rates of readmissions, with a mean of 4.65 per heart transplant patient and 4.53 per LVAD patient (P = .87). One-year survival rate was 87.8% for heart transplant patients and 78.0% for LVAD patients (P = .04). In assessing charges and costs for all readmissions within the first year of the index operation, there were no statistically significant differences between the 2 groups (Table 3). There was, however, a trend toward increased total charges accrued for heart transplants in the first year compared with LVADs ($169 732 ± $242 366 for LVAD vs $201 682 ± $297 565 for heart transplant), but this did not reach statistical significance (P = .08).

In assessing overall charges and costs for 1 year, the mean total charges were $1 029 732 ± $450 498 for LVAD and $927 559 ± $562 404 for heart transplant (P = .49) (Table 4). A statistical significance was found between the 2 groups regarding total indirect fixed costs ($76 936 ± $44 500 for LVAD vs $103 986 ± $46 670 for heart transplant; P = .04) and total direct variable costs ($198 452 ± $70 972 for LVAD vs $139 494 ± $82 455 for heart transplant; P = .04) and a trend toward statistical difference regarding total direct fixed costs ($29 819 ± $20 135 for LVAD vs $43 073 ± $21 842 for heart transplant; P = .09). Of note, there was no statistical significance found between the 2 groups regarding total costs for 1 year (P = .48).

Discussion

Although there are data emerging regarding the substantial costs associated with surgical therapy for end-stage heart failure, it is difficult to draw conclusions given the significant institutional variability that exists across the Unites States.

Left ventricular assist device technology is becoming more commonly prevalent in the landscape of heart failure treatment. Implant of these devices has increased annually in the United States, with absolute numbers of 1542 in 2010, 1798 in 2011, 2169 in 2012, and 2511 in 2013. In addition to the total number of devices, the strategy used during the implant procedure also has changed, with designation as “destination therapy” increasing (from 554 in 2010 to 1123 in 2013), whereas LVAD use as bridge to transplant has remained stable, dropping from 474 in 2010 to 429 in 2011 and 437 in 2012.5 The burden created by heart transplant on US health care is rising; total costs covered by Medicare part A for heart transplants were $273 002 263 in 2008, $295 983 294 in 2009, and $311 817 476 in 2010. Total costs covered by Medicare part B for heart transplants were $82 640 717 in 2008, $98 914 517 in 2009, and $100 072 579 in 2010.2 As technology improves, LVAD costs may continue to decrease and bridge the gap between direct heart transplant for the initial index admission. We must approach heart failure therapy in a fiscally responsible manner, while continuing to implement effective treatments in a cost-saving manner.

When we view our institutional data regarding the cost effectiveness of heart transplant versus LVAD procedures, it is apparent that, although there are some differences in the type of costs between the 2 therapies, there are no significant differences in total 1-year costs. In addition, we discovered that there was no significant difference in charges or costs for all readmissions within 1 year. Finally, we determined that index admission charges and costs revealed no significant difference as well. These data support the conclusion that LVAD therapy and heart transplant therapies may be equivalent in institutional charges and costs to the patient. Noting the lack of significant cost differences between the 2 groups and similar rates of readmission and 1-year survival rates, compounded by the limited availability of hearts available for transplant annually, LVAD therapy for end-stage heart failure is an increasingly important consideration for treatment. This must be weighed with the fact that there is a difference of 1-year survival that is approximately 10% between the 2 therapies, favoring heart transplant for outcome.

One must remain guarded, however, that inpatients with worsening heart failure have the highest rate of mortality, all-cause readmission, and Medicare payments.⁷ As such, allowing patients to wait for a suitable organ, which may not become available, may harm the patient both physically and financially.

From a fiscal perspective, primary heart transplant may be the most cost-effective approach to treating patients with advanced heart failure. However, the lack of suitable donors for many of these patients clearly highlights the value of LVADs in the armamentarium of advanced heart failure surgical options.^8,9

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