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The Journal of Heart and Lung Transplantation
International Society for Heart and Lung Transplantation.

Cost-effectiveness of bivalirudin in pediatric ventricular assist devices

Published:October 11, 2022DOI:https://doi.org/10.1016/j.healun.2022.10.006

      Background

      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.

      Methods

      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).

      Results

      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.

      Conclusions

      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.

      KEYWORDS

      Abbreviations:

      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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