Schaffer Elisabeth M, Su Rebecca Giok Sim, Chay Junxing, Finkelstein Eric A
Saw Swee Hock School of Public Health, National University of Singapore, Singapore.
Health Services and Systems Research, Duke-NUS Medical School, Singapore.
JAMA Netw Open. 2025 Apr 1;8(4):e254483. doi: 10.1001/jamanetworkopen.2025.4483.
Singapore is considering subsidizing left ventricular assist devices (LVADs) for end-stage heart failure (ESHF) and uses cost-effectiveness evidence to inform the determination. Yet, no economic evaluation has thus far been conducted.
To estimate the lifetime cost-effectiveness of LVAD compared with optimal medical management for transplant-ineligible patients.
DESIGN, SETTING, AND PARTICIPANTS: This economic evaluation used a Markov model to simulate survival, stroke incidence, other adverse events, and heart failure hospitalizations for a cohort of adult patients in Singapore with transplant-ineligible ESHF, most of whom were inotrope dependent. Latest LVAD mortality data from a randomized clinical trial were age-adjusted, and an indirect comparison of prior trial results was performed to estimate survival for inotrope-dependent and inotrope-independent patients. Costs were estimated (in 2023 Singapore dollars [SGD]) using cohort billing data from 2017 to 2022 and National Heart Centre Singapore LVAD charges. Statistical analysis was performed from December 2023 to July 2024.
HeartMate 3 LVAD (Abbott).
Health care costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio (ICER) evaluated against a threshold of SGD 114 000 (US $85 075) per QALY gained.
At model initiation, the cohort had a mean (SD) age of 64 (12) years, and 78% (range, 68%-86%) of patients were inotrope dependent. In the base case analysis, LVAD yielded an additional 3.45 QALYs at an incremental cost of SGD 404 678 (US $301 999), producing an ICER of SGD 117 370 (US $87 590) per QALY gained for the transplant-ineligible population. The ICER differed for inotrope-use subgroups at SGD 106 458 (US $79 446) per QALY gained for inotrope-dependent patients and SGD 174 798 (US $130 446) per QALY gained for inotrope-independent patients (with 59% and 19% probabilities, respectively, of attaining high value). The inotrope-dependent ICER was sensitive to model input changes and structural assumptions, whereas the inotrope-independent ICER consistently exceeded the high-value threshold in scenario analyses. In threshold analyses, a 44% reduction in the total implantation price or a 54% reduction in the all-cause mortality hazard were required for LVAD to be high value for inotrope-independent patients. Confidence that the inotrope-dependent ICER is high value increased to 75% and 85% with respective 20% and 33% reductions in total implantation price.
In this economic evaluation comparing LVAD with optimal medical management, LVAD was potentially high value for most transplant-ineligible patients who are inotrope dependent. Confidence in this result was improved with plausible price reductions, yet only extreme changes rendered LVAD high value for inotrope-independent patients.
新加坡正在考虑为终末期心力衰竭（ESHF）患者补贴左心室辅助装置（LVAD），并利用成本效益证据来做出决策。然而，迄今为止尚未进行经济评估。
评估与最佳药物治疗相比，LVAD对不符合移植条件患者的终身成本效益。
设计、背景和参与者：这项经济评估使用马尔可夫模型来模拟新加坡一组不符合移植条件的成年ESHF患者的生存情况、中风发生率、其他不良事件以及心力衰竭住院情况，其中大多数患者依赖血管活性药物。对一项随机临床试验的最新LVAD死亡率数据进行年龄调整，并对先前试验结果进行间接比较，以估计依赖和不依赖血管活性药物患者的生存率。使用2017年至2022年的队列计费数据和新加坡国家心脏中心的LVAD收费来估计成本（以2023年新加坡元[SGD]计）。统计分析于2023年12月至2024年7月进行。
HeartMate 3 LVAD（雅培公司）。
以每获得一个质量调整生命年（QALY）114000新加坡元（85075美元）为阈值，评估医疗保健成本、QALY和增量成本效益比（ICER）。
在模型开始时，该队列的平均（标准差）年龄为64（12）岁，78%（范围为68%-86%）的患者依赖血管活性药物。在基础病例分析中，LVAD在增量成本为404678新加坡元（301999美元）的情况下额外产生了3.45个QALY，对于不符合移植条件的人群，每获得一个QALY的ICER为117370新加坡元（87590美元）。对于依赖血管活性药物的患者，每获得一个QALY的ICER为106458新加坡元（79446美元），对于不依赖血管活性药物的患者，每获得一个QALY的ICER为174798新加坡元（130446美元）（分别有59%和19%的概率达到高价值）。依赖血管活性药物的ICER对模型输入变化和结构假设敏感，而在情景分析中，不依赖血管活性药物的ICER始终超过高价值阈值。在阈值分析中，LVAD要对不依赖血管活性药物的患者具有高价值，总植入价格需要降低44%或全因死亡风险降低54%。随着总植入价格分别降低20%和33%，对依赖血管活性药物的ICER为高价值的信心分别提高到75%和85%。
在这项将LVAD与最佳药物治疗进行比较的经济评估中，对于大多数依赖血管活性药物且不符合移植条件的患者，LVAD可能具有高价值。通过合理的价格降低，对这一结果的信心得到了提高，但只有极端变化才能使LVAD对不依赖血管活性药物的患者具有高价值。
Zotero 插件
