Orthotopic heart transplant versus left ventricular assist device: a national comparison of cost and survival

Abstract

Objectives: Orthotopic heart transplantation is the standard of care for end-stage heart disease. Left ventricular assist device implantation offers an alternative treatment approach. Left ventricular assist device practice has changed dramatically since the 2008 Food and Drug Administration approval of the HeartMate II (Thoratec, Pleasanton, Calif), but at what societal cost? The present study examined the cost and efficacy of both treatments over time.

Methods: All patients who underwent either orthotopic heart transplantation (n = 9369) or placement of an implantable left ventricular assist device (n = 6414) from 2005 to 2009 in the Nationwide Inpatient Sample were selected. The trends in treatment use, mortality, and cost were analyzed.

Results: The incidence of orthotopic heart transplantation increased marginally within a 5-year period. In contrast, the annual left ventricular assist device implantation rates nearly tripled. In-hospital mortality from left ventricular assist device implantation decreased precipitously, from 42% to 17%. In-hospital mortality for orthotopic heart transplantation remained relatively stable (range, 3.8%-6.5%). The mean cost per patient increased for both orthotopic heart transplantation and left ventricular assist device placement (40% and 17%, respectively). With the observed increase in both device usage and cost per patient, the cumulative Left ventricular assist device cost increased 232% within 5 years (from $143 million to $479 million). By 2009, Medicare and Medicaid were the primary payers for nearly one half of all patients (orthotopic heart transplantation, 45%; left ventricular assist device, 51%).

Conclusions: Since Food and Drug Administration approval of the HeartMate II, mortality after left ventricular assist device implantation has decreased rapidly, yet has remained greater than that after orthotopic heart transplantation. The left ventricular assist device costs have continued to increase and have been significantly greater than those for orthotopic heart transplantation. Because of the evolving healthcare economics climate, with increasing emphasis on the costs and comparative effectiveness, a concerted effort at LVAD cost containment and judicious usage is essential to preserve the viability of this invaluable treatment.

FIGURE 1

Treatment usage over time showing the number of patients undergoing either orthotopic heart transplantation (OHT) or left ventricular assist device (LVAD) implantation from 2005 to 2009.

FIGURE 2

Unadjusted in-hospital mortality showing percentage of patients dying during the index hospitalization for either orthotopic heart transplantation (OHT) or left ventricular assist device (LVAD) implantation from 2005 to 2009.

FIGURE 3

Estimated cost of index hospitalization for either orthotopic heart transplantation (OHT) or left ventricular assist device (LVAD) implantation. A, Mean per-patient cost for OHT and LVAD from 2005 to 2009, in thousands of US dollars. B, Total nationwide expenditures for OHT and LVAD index hospitalizations from 2005 to 2009, shown in billions of US dollars. C, Total Medicare and Medicaid expenditures for OHT and LVAD index hospitalizations from 2005 to 2009, shown in billions of US dollars.

FIGURE 4

Discharge disposition of patients discharged alive after undergoing either orthotopic heart transplantation (OHT) or left ventricular assist device (LVAD) implantation from 2005 to 2009. Data shown as percentages of total discharges grouped according discharge disposition: routine, home with home healthcare, skilled nursing facility or intermediate care facility (SNF/ICF), and short-term hospital.