The Cost-effectiveness of Transplanting Hearts From Hepatitis C-infected Donors Into Uninfected Recipients

Abstract

Background: The DONATE HCV trial demonstrated the safety and efficacy of transplanting hearts from hepatitis C viremic (HCV+) donors. In this report, we examine the cost-effectiveness and impact of universal HCV+ heart donor eligibility in the United States on transplant waitlist time and life expectancy.

Methods: We developed a microsimulation model to compare 2 waitlist strategies for heart transplant candidates in 2018: (1) status quo (SQ) and (2) SQ plus HCV+ donors (SQ + HCV). From the DONATE HCV trial and published national datasets, we modeled mean age (53 years), male sex (75%), probabilities of waitlist mortality (0.01-0.10/month) and transplant (0.03-0.21/month) stratified by medical urgency, and posttransplant mortality (0.003-0.052/month). We assumed a 23% increase in transplant volume with SQ + HCV compared with SQ. Costs (2018 United States dollar) included waitlist care ($2200-190 000/month), transplant ($213 400), 4-wk HCV treatment ($26 000), and posttransplant care ($2500-11 300/month). We projected waitlist time, quality-adjusted life-years (QALYs), lifetime costs, and incremental cost-effectiveness ratios (ICERs [$/QALY, discounted 3%/year]; threshold ≤$100 000/QALY).

Results: Compared with SQ, SQ + HCV decreased waitlist time from 8.7 to 6.7 months, increased undiscounted life expectancy from 8.9 to 9.2 QALYs, and increased discounted lifetime costs from $671 400/person to $690 000/person. Four-week HCV treatment comprised 0.5% of lifetime costs. The ICER of SQ + HCV compared with SQ was $74 100/QALY and remained ≤$100 000/QALY with up to 30% increases in transplant and posttransplant costs.

Conclusions: Transplanting hearts from HCV-infected donors could decrease waitlist times, increase life expectancy, and be cost-effective. These findings were robust within the context of current high HCV treatment costs.

FIGURE 1.

Cumulative component average lifetime costs for heart transplant candidates when HCV+ hearts are ineligible for transplant (left) and when HCV+ hearts are eligible for transplant (right). Cumulative component costs per person include posttransplant costs (dark gray), waitlist medical intervention costs (dark blue), transplant cost (light blue), and DAA cost (green). The total per-person cost is in bold above each bar. Within each bar are component cost and the percentage of the total cost for that strategy. DAA, 4-wk direct-acting antivirals; HCV, hepatitis C; SQ, status-quo; USD, United States dollar.

FIGURE 2.

One-way sensitivity analyses assessing the impact of model input parameter ranges on the cost-effectiveness of transplanting hepatitis C-infected hearts into uninfected recipients in the United States. The horizontal axis shows the ICER ($/QALY) of SQ + HCV compared with SQ. The vertical axis lists input parameters in order of influence on the base-case ICER, with the greatest influencing parameters at the top of the graph. Within the parentheses next to each parameter is the base-case input value followed by the range of values evaluated. The base-case ICER is represented by the solid black vertical line ($74 100/QALY). An ICER was considered “cost-effective” if it was <$100 000/QALY (dashed orange line). A more stringent threshold of $50 000/QALY (dashed green line) was also considered. The ICER of SQ + HCV vs SQ was not sensitive to the increase in transplant volume. HCV; hepatitis C virus; DAA, 4-wk direct-acting antivirals; ICER, incremental cost-effectiveness ratio; QALY, quality-adjusted life-year; SQ, status-quo.

FIGURE 3.

Two-way sensitivity analyses assessing the joint impact of short-course direct-acting antiviral cost (x-axis) and waitlist costs (y-axis) on the cost-effectiveness of transplanting hepatitis C-infected hearts into uninfected recipients in the United States. The horizontal axis shows the cost of short-course direct-acting antivirals in $5000 increments, and the vertical axis shows waitlist costs ranging from 0.33 to 2.00x base-case input values (see Tables 1–3). The black “X” reflects the base-case ICER of SQ + HCV compared with SQ; red shading reflects ICERs >$100 000/QALY (ie, not cost-effective); light-green shading reflects ICERs >$50 000/QALY and ≤$100 000/QALY (ie, cost-effective); dark-green shading reflects ICERs >$0/QALY and ≤$50 000/QALY (ie, very cost-effective); blue shading reflects negative ICERs (ie, cost-saving). DAA, 4-wk direct-acting antiviral; ICER, incremental cost-effectiveness ratio; QALY, quality-adjusted life-year; USD, United States dollar.