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)To read this article in full you will need to make a payment
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Article info
Publication history
Published online: October 11, 2022
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