Cost-Effectiveness of Routine Surveillance Endomyocardial Biopsy After 12 Months Post-Heart Transplantation
Cost-Effectiveness of Routine Surveillance Endomyocardial Biopsy After 12 Months Post-Heart Transplantation
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DOI：
10.1161/circheartfailure.114.001199
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发表时间：
2014-09-01
影响因子：
9.7
通讯作者：
Smith, Kenneth J.
中科院分区：
文献类型：
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作者：
Lampert, Brent C.;Teuteberg, Jeffrey J.;Smith, Kenneth J.
背景-尽管心脏移植（HT）后晚期排斥反应的风险较低，但监测心内膜心肌活检（EMB）通常会持续数年。我们评估了常规EMB的成本效益后12个月后HT。方法和结果-马尔可夫模型比较了以下监测EMB策略的基线策略停止EMB后12个月HT：（1）HT后第2年每4个月一次，（2）第2年每6个月一次，（3）第2 - 3年每4个月一次，以及（4）第2至3年每6个月一次。患者在HT后12个月进入模型，并随访至36个月。在所有策略中，患者有EMB症状;在12个月后的活检策略中，无论症状如何，也按计划进行EMB。进行了单因素和Monte Carlo敏感性分析。在12个月时停止EMB是占主导地位的（更有效，成本更低），与次佳策略（第2年每6个月）相比，每位患者节省2884美元，并获得0.0011质量调整生命年。第2年至第3年无症状排斥反应的年风险从先前报告的2.5%增加到8.5%，导致第2年每6个月进行一次活检的策略获得0.0006质量调整生命年，但每获得一质量调整生命年的成本为4913599美元。当未经治疗的无症状排斥反应的死亡率接近11%时，12个月的EMB也不再占主导地位;当风险接近99%时，竞争策略的成本仍大于20万美元/质量调整生命年。结论-HT后12个月的监测EMB比12个月后进行的EMB更有效且成本更低，除非无症状细胞排斥反应的风险及其死亡率明显高于之前观察到的。
Background-Despite low risk of late rejection after heart transplant (HT), surveillance endomyocardial biopsies (EMBs) are often continued for years. We assessed the cost-effectiveness of routine EMB after 12 months post-HT.Methods and Results-Markov model compared the following surveillance EMB strategies to baseline strategy of stopping EMB 12 months post-HT: (1) every 4 months during year 2 post-HT, (2) every 6 months during year 2, (3) every 4 months for years 2 to 3, and (4) every 6 months for years 2 to 3. Patients entered the model 12 months post-HT and were followed until 36 months. In all strategies, patients had EMB with symptoms; in biopsy strategies after 12 months, EMB was also performed as scheduled regardless of symptoms. One-way and Monte Carlo sensitivity analyses were performed. Stopping EMB at 12 months was dominant (more effective, less costly), saving $2884 per patient compared with the next best strategy (every 6 months for year 2) and gaining 0.0011 quality-adjusted life-years. Increasing the annual risk of asymptomatic rejection in years 2 to 3 from previously reported 2.5% to 8.5% resulted in the biopsy every 6 months for year 2 strategy gaining 0.0006 quality-adjusted life-years, but cost $4 913 599 per quality-adjusted life-year gained. EMB for 12 months was also no longer dominant when mortality risk from untreated asymptomatic rejection approached 11%; competing strategies still cost >$200 000 per quality-adjusted life-year as that risk approached 99%.Conclusions-Surveillance EMB for 12 months post-HT is more effective and less costly than EMB performed after 12 months, unless risks of asymptomatic cellular rejection and its mortality are strikingly higher than previously observed.