The Journal of Heart and Lung Transplantation
International Society for Heart and Lung Transplantation.
Research Article| Volume 42, ISSUE 3, P390-397, March 2023

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Cost-effectiveness of bivalirudin in pediatric ventricular assist devices

Published:October 11, 2022DOI:


      Despite recent data suggesting improved outcomes with bivalirudin vs heparin in pediatric Ventricular assist devices (VAD), higher costs remain a barrier. This study quantified trends in bivalirudin use and compared outcomes, resource utilization, and cost-effectiveness associated with bivalirudin vs heparin.


      Children age 0 to 6 year who received VAD from 2009 to 2021 were identified in Pediatric Health Information System. Bivalirudin use was evaluated using trend analysis and outcomes were compared using Fine-Gray subdistrubtion hazard ratios (SHR). Daily-level hospital costs were compared due to differences in length of stay. Cost-effectiveness was evaluated using incremental cost-effectiveness ratio (ICER).


      Of 691 pediatric VAD recipients (median age 1 year, IQR 0-2), 304 (44%) received bivalirudin with 90% receiving bivalirudin in 2021 (trend p-value <0.01). Bivalirudin had lower hospital mortality (26% vs 32%; adjusted SHR 0.57, 95% CI 0.40-0.83) driven by lower VAD mortality (20% vs 27%; adjusted SHR 0.46, 95% CI 0.32-0.77) after adjusting for year, age, diagnosis, and center VAD volume. Post-VAD length of stay was longer for bivalirudin than heparin (median 91 vs 64 days, respectively, p < 0.001). Median daily-level costs were lower among bivalirudin (cost ratio 0.87, 95% CI 0.79-0.96) with higher pharmacy costs offset by lower imaging, laboratory, supply, and room/board costs. Estimated ICER for bivalirudin vs heparin was $61,192 per quality-adjusted life year gained with a range of $27,673 to $131,243.


      Bivalirudin use significantly increased over the past decade and is now used in 90% young pediatric VAD recipients. Bivalirudin was associated with significantly lower hospital mortality and an ICER <$65,000, making it a cost-effective therapy for pediatric VAD recipients.



      ACTION (advanced cardiac therapies improving outcomes network), AT3 (antithrombin 3), CCC (chronic complex comorbidity), CHA (children's hospital association), CHD (congenital heart disease), ECMO (extracorporeal membrane oxygenation), ICER (incremental cost-effectiveness ratio), ICU (intensive care unit), LOS (length of stay), PHIS (pediatric health information system), pRBC (packed red blood cell), QALY (quality-adjusted life years), RCC (ration of cost-to-charge), VAD (ventricular assist device), VAQOL (visual analog quality of life scale)
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