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J Thorac Cardiovasc Surg 2009;138:480-485
© 2009 The American Association for Thoracic Surgery

Cardiothoracic Transplantation

Left ventricular assist device as destination therapy: Application of the payment-by-results approach for the device reimbursement

Andrea Messori, PharmDa,*, Sabrina Trippoli, PharmDa, Massimo Bonacchi, MDb, Guido Sani, MDb

a Laboratory of Pharmacoeconomics, University Hospital of Careggi, Firenze, Italy
b Cardiac Surgery, Department of Medical-Surgical Critical Area, University of Florence, Firenze, Italy

Received for publication October 28, 2008; revisions received January 10, 2009; accepted for publication February 12, 2009.

* Address for reprints: Andrea Messori, PharmD, Azienda Careggi, Viale Pieraccini 17, 50134 Firenze, Italy. (Email: andreamessori{at}interfree.it).

Objective: Value-based methods are increasingly used to reimburse therapeutic innovation, and the payment-by-results approach has been proposed for handling interventions with limited therapeutic evidence. Because most left ventricular assist devices are supported by preliminary efficacy data, we examined the effectiveness data of the HeartMate (Thoratec Corp, Pleasanton, CA) device to explore the application of the payment-by-results approach to these devices and to develop a model for handling reimbursements.

Methods: According to our model, after establishing the societal economic countervalue for each month of life saved, each patient treated with one such device is associated to the payment of this countervalue for every month of survival lived beyond the final date of estimated life expectancy without left ventricular assist devices. Our base-case analysis, which used the published data of 68 patients who received the HeartMate device, was run with a monthly countervalue of \#8364;5000, no adjustment for quality of life, and a baseline life expectancy of 150 days without left ventricular assist devices. Sensitivity analysis was aimed at testing the effect of quality of life adjustments and changes in life expectancy without device.

Results: In our base-case analysis, the mean total reimbursement per patient was \#8364;82,426 (range, \#8364;0 to \#8364;250,000; N = 68) generated as the sum of monthly payments. This average value was close to the current price of the HeartMate device (\#8364;75,000). Sensitivity testing showed that the base-case reimbursement of \#8364;82,426 was little influenced by variations in life expectancy, whereas variations in utility had a more pronounced impact.

Conclusion: Our report delineates an innovative procedure for appropriately allocating economic resources in this area of invasive cardiology.

Abbreviations and Acronyms AST = additional survival time; bLE = baseline life expectancy; indST = individual survival time; LVAD = left ventricular assist device; MCV = monthly countervalue






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