Abstract 3772: Alternate Listing Transplantation is a Cost-Effective Treatment for End-Stage Heart Failure Patients
BACKGROUND: In order to offer the benefit of heart transplantation to a greater number of patients some centers match high-risk recipients (HR) with non-standard or ”marginal” donors (MD) in a strategy known as Alternate Listing Transplantation (ALT). However, pairing sicker recipients with lower quality donor organs remains both clinically and ethically controversial. The purpose of this study was to determine the cost-effectiveness of this strategy.
METHODS: The United Network of Organ Sharing provided deidentified patient-level data. UNOS data was used to determine clinical outcomes, including waiting time, post-transplant survival, length of stay, re-hospitalizations, episodes of rejection, and infection, based on all adult heart transplant candidates (age [gt] 18 yo) and listed between 1995–2005 (n=35,049). Through a systematic literature review of randomized controlled trials and case series that estimated related costs, a cost model (see Table⇓) using an intention-to-treat assumption was developed to calculate the incremental cost-effectiveness ratio (ICER) for HR candidates who subsequently received marginal donor hearts (HTR) compared with candidates who were not transplanted (NTXP). High-risk recipient criteria included age [gt] 65yo, retransplantation, HepC+, HIV+, CrCl <30 ml/min, DM with PVD, DM with Crcl <40 ml/min. MD criteria included age [gt] 55yo, DM, HIV+, HepC+, EF<45%, and donor:recipient weight <0.7.
RESULTS: Median survival from listing was 0.55 yrs and 5.1 yrs in the HTR and NTXP groups, respectively. The estimated ICER was $66,645($34,046–$127,491) ICER varied by HR recipient criteria.
CONCLUSIONS: The ICER for ALT falls at the upper limits acceptability for being cost-effective. However, stratified analysis by HR group suggests that this strategy is not appropriate for all groups.