Heart transplant without an LVAD bridge is the most cost-effective course, but the sickest patients often cannot continue waiting without circulatory support. BTT with transplant requires two major operations with considerable hospital time for both procedures, expectedly making this approach costly [29]. Studies have identified reimbursement for LVAD support as inadequate when compared to transplant; however, third-party payer reimbursement has improved along with better survival making BTT more cost-effective [30, 31]. In a more recent head-to-head cost comparison of heart transplant to LVAD support at 1 year, the average cost was approximately $40,000 high for LVAD support, but this difference was not statistically significant [32]. Comparison of LVAD support to heart transplant is problematic since patients undergoing LVAD implant for BTT are likely to be much sicker or are at higher risk of death than patients undergoing elective transplant. Furthermore, LVAD support in the sickest transplant candidates optimizes organ function and physical status lowering the risk of post-transplant complications. Cost-effective comparisons inherently give transplant an advantage [33].

In the Center for Medicare Medicaid Services, Medicare Provider Analysis and Review (MEDPAR) file contains data from claims for services provided to beneficiaries admitted to Medicare certified inpatient hospitals. MEDPAR 2013 hospital cost reported the volume, length of stay (days), and average cost for implanting an LVAD and heart transplantation (◘ Table 57.2). The hospital cost for implanting an LVAD, which includes the additional expense of the device and accessories, is becoming similar to heart transplantation cost.

The UK National Institute of Health Research, analyzing the clinical effectiveness and cost-effectiveness of LVADs as BTT, completed a systematic review and cost-effectiveness model [37]. The aims of this study were to determine the clinical effectiveness and cost-effectiveness of continuous-flow LVADs used for BTT versus medical therapy and BTT versus destination therapy. The systematic review included devices approved for BTT by the US Food and Drug Administration and Conformité Européenne (CE) approved – the two systems with results were the HeartMate II and the HVAD. Forty publications were identified to provide the outcome data, while cost-effectiveness data was gathered from implants performed at six institutions in the United Kingdom. There were no randomized controlled trials in the analysis. A semi-Markov model with multiple sensitivity analyses varying survival, utilities, and cost inputs to the model was used. The model outputs were incremental cost-effectiveness ratios (ICERs), cost-/quality-adjusted life-years (QALYs) gained and cost/life-year gained (LYG). They reported that the 3-year, 10-year, and lifetime ICERs for BTT with an LVAD compared to medical management are higher than generally applied to willingness-to-pay thresholds. Nonetheless, at a lifetime time horizon, the ICERs approximate the threshold values used in end-of-life assessments. They had determined that LVADs for BTT yields ICERs of £122,730, £68,088, and £55,173, respectively, when compared with medical management.

At a lifetime horizon, using VADs as an alternative to transplant (ATT) rather than as a BTT was complex and had a reduced cost and reduced quality-adjusted life-years (QALYs). ATT when evaluated over a lifetime was £20,637 less costly than BTT for each QALY year. An important conclusion from this study was the need of published studies that include cost with survival, quality of life, functional capacity, and adverse event rates.

During the HeartMate II clinical trial, a Markov model was developed to assess cost-effectiveness of DT as compared to medical management [38]. Survival, hospitalization rates, quality of life, and cost data were analyzed for advanced heart failure patients treated with LVAD support or medical therapy. Clinical outcomes were obtained from the medical therapy arm of the REMATCH trial and from patients treated with an LVAD in the HeartMate II destination therapy clinical trial. The cost of heart failure admissions was estimated with Medicare prospective payments, and the cost of LVAD implantation was obtained from hospital claims during the clinical trial. Compared to patients treated with optimal medical therapy, continuous-flow LVAD patients had higher 5-year costs ($360,407 versus $62,856), QALYs (1.87 versus 0.37), and life-years (2.42 versus 0.64). The ICER of the continuous-flow device was $198,184 per QALY and $167,208 per life-year. This equates to a 75% reduction in ICER compared to the $802,700 per QALY for the pulsatile-flow device. The results were most sensitive to the cost of device implantation, long-term survival, cost per re-hospitalization, and utility associated with patients’ functional status. This study concluded that cost-effectiveness of LVAD support was improving for patients treated for destination therapy with the newer continuous-flow LVAD. These results were attributed to better survival, lower costs of implantation, and better functional capacity of supported patients. Although the ICER/QALY was higher than the conventional $50,000, the high rate of cost reduction was very encouraging. The observed 75% reduction in QALY/year occurred during a time when LVAD implants were increasing substantially with the anticipation of further improvements. The findings and conclusions of this study were at a time when the use of continuous-flow LVADs was relatively early, and with clinical experience, efficiency and survival are likely.