The high cost of getting a left ventricular assist device (LVAD) for advanced heart failure, compounded by expensive follow-up care, makes these devices a “relatively low value,” researchers said. LVAD implantation cost $175,420 for the procedure but carried a 6-year total price tag of $726,200, according to Jacqueline B. Shreibati, MD, MS, of Stanford University School of Medicine, Calif., and colleagues in a study published online in JACC: Heart Failure. For destination therapy in ambulatory patients, LVAD therapy cost $209,400 per quality-adjusted life year gained (or $597,400 per life-year gained) relative to medical management alone. For higher-risk patients with multiple comorbidities often considered LVAD ineligible, the incremental cost-effectiveness ratio was $171,000 per quality-adjusted life year gained, relative to medical management. If readmission rates and outpatient costs could be halved after LVAD implantation, the relative price of therapy would drop to $86,900 per quality-adjusted life year gain for low-risk patients, the authors found. “Across a spectrum of advanced heart failure patients, we found that the high frequency of readmissions and the high cost of outpatient care, over a longer period of survival, were the largest determinants of the relatively low value provided by LVAD therapy,” Shreibati’s group wrote. “Based upon this analysis, multidisciplinary teams should focus upon reducing outpatient costs and rehospitalizations,” concluded Joseph G. Rogers, MD, of Duke Clinical Research Institute in Durham, N.C., in an accompanying editorial, listing the challenges of both approaches. “The costs of managing outpatients supported with mechanical blood pumps require careful examination, particularly the costs of durable medical equipment and supplies,” Rogers wrote. “Future innovation that includes totally implantable systems may obviate the need for some of the supplies but will certainly be associated with higher upfront costs as well as yet undefined maintenance costs.” The second goal of reducing re-hospitalizations is also fraught with difficulty, according to the editorialist. “Like the early days of transplant in which nearly all physiological perturbations resulted in hospitalization, VAD patients are hospitalized with impunity. Clinicians do not yet have the confidence or the tools to manage many of the VAD adverse events in the outpatient setting. [Furthermore], many of the complications such as mucosal bleeding, stroke, and device malfunction require inpatient care.” Even so, these barriers to greater access to LVADs signal the need for more innovation, Rogers suggested. “While LVADs do not appear to provide high value by current benchmarks, there are currently few other effective treatments for the 250,000 patients with advanced heart failure,” Shreibati and co-authors noted. Their study of Medicare claims included data on LVAD implantations in 220 patients in 2009 or 2010. Another set of claims from 2008 to 2011 was used to determine before-and-after use of inpatient and outpatient care, other services, and durable medical equipment. After device placement, readmissions became more common and more expensive ($19,465 versus $12,377, P<0.001), while monthly outpatient costs stayed stable. A lifetime simulation found that the LVAD was associated with increased quality-adjusted life-years (4.41 versus 2.67), readmissions (13.03 versus 6.35), and costs ($726,200 versus $361,800). Shreibati and colleagues acknowledged the high probability of selection bias in their study. The data also primarily came from white men, limiting the generalizability of the results. “While this paper highlights the potential value of LVAD therapy, there are several caveats that should be considered in its interpretation,” Rogers agreed. “The field of assisted circulation is rapidly evolving with new technologies and improved patient selection and management strategies. The data used in this analysis is 6-7 years old, a time at which these devices had just completed clinical trial. As a result, this information may not be representative of contemporary state and does not account for changes in the incidence or cost of managing adverse events.” Additionally, he commented, “the analysis of outpatient costs is based upon a small number of patients (n=45) and may not reflect the larger LVAD population.” Disclosures Shreibati and Rogers reported no relevant conflicts of interest. Study co-authors disclosed relationships with HeartWare, Thoratec, HeartFlow, Zoll, Acumen, and Jansson.