Taking first suitable heart may benefit cost, survival in children needing transplantation

CHICAGO — For children who most urgently require heart transplantation, taking the first suitable offer of a new organ was less costly and resulted in better survival than waiting for a negative prospective crossmatch, researchers reported at the American Heart Association Scientific Sessions.

Some children with antibodies that may cause rejection of the transplant are listed with a requirement for a negative prospective crossmatch; however, while previous research showed a survival benefit associated with not having that requirement, the cost effectiveness of the two strategies was unknown, according to study background.

“Historically, it was assumed that survival after heart transplantation across a positive donor-specific crossmatch was so poor that listing such candidates should be avoided, or at the least a negative crossmatch prior to transplantation [should] be mandated,” Brian Feingold, MD, MS, medical director of the pediatric heart failure and transplantation program at Children’s Hospital of Pittsburgh of UPMC, told Cardiology Today. “We have found, using historical registry data, that this is not the case, and that when considered from the time of listing, costs are less and survival greater when the first otherwise suitable organ offer is accepted for candidates who urgently require transplantation.”

Brian Feingold

Using a Markov-state transition model with a 10-year time horizon, Feingold and colleagues examined survival, cost and quality of life using data from more than 2,700 children listed for a heart transplant in the United States between 1999 and 2009. The model enabled researchers to compare costs and quality of life-adjusted survival from the time of listing for transplantation, according to whether the candidate was required to have a negative prospective crossmatch before an organ offer was accepted.

Feingold and colleagues estimated that a waitlist strategy of accepting the first suitable organ offer cost an average of $122,856 less and gained 1.04 more quality-adjusted life-years compared with waiting for transplantation based on antibody status.

When researchers varied model estimates of cost, quality of life, and waitlist and post-transplant survival over clinically plausible ranges, the first-suitable-organ strategy remained cost effective or cost saving at the commonly accepted willingness-to-pay threshold of $100,000 per quality-adjusted life-year.

“Amidst the critical shortage of donor hearts for children in the [United States], we must carefully consider how to optimally allocate donor organs to maximize survival while keeping costs bearable,” Feingold said in an interview. “Our work supports that candidacy for pediatric heart transplantation should not be denied on the basis of sensitization status alone. However, it is very important to realize this is just one subgroup of candidates in need of transplantation, and that further study should address the impact of adopting this strategy on utilization and allocation of these precious resources among all candidates.” – by Erik Swain

For more information:

Feingold B. Abstract #15622. Presented at: American Heart Association Scientific Sessions; Nov. 15-19, 2014; Chicago.

Disclosure: Feingold reports receiving a research grant from the NIH.