More Hearts, Shorter Waits, and Fewer Deaths
– with a Great Bottom Line
by Adrienne Mueller, PhD
November 11, 2021
A heart undergoes a lot of scrutiny before it can be used in a transplant. How well does the tissue match the transplant recipient? Does the heart seem to function normally? Was the donor healthy – or did they have any diseases that could be passed on to the host? Hearts that pass all of these tests are rare – and far too few to meet the demand of patients. But what if we could find a way to make more hearts cleared for transplant?
Hepatitis C is a disease that affects approximately 2.5 million people in the US; and about 2.7% of potential heart donors are Hepatitis C-positive. The good news is that current anti-viral therapies for Hepatitis C are extremely effective – and have cure rates of approximately 95%. Previous studies show that for an individual patient, the benefits of taking a Hepatitis C-positive heart probably outweigh the (fairly high) anti-viral costs and (very low) infection risk. But what about at the system level? How will transplanting additional hearts that need antiviral medication impact the healthcare system in terms of organ access, waitlists and cost?
First-author Brian Wayda, MD, and senior author Kiran Khush, MD led a study designed to answer exactly these question that was recently published in the Journal of Heart and Lung Transplantation. Wayda et al simulated what would happen if approximately 20,000 heart transplant candidates were willing to also accept Hepatitis C-positive donor hearts. To do this, they used detailed histories and outcomes data from US adults listed for heart transplant, covering a wide range of geographic and clinical backgrounds. The investigators looked at the impact of using hepatitis C-positive hearts on the number of transplants made, waitlist times and outcomes, lifetime costs, and, importantly, quality-adjusted life years. They found that 232 more transplants were able to be performed and 132 individuals were able to receive
transplants before being ‘delisted’ from the waitlist due to deterioration. Moreover, there were 50 fewer waitlist deaths and wait times were reduced by 3-11%. Critically, this simulated intervention was also cost-effective: patients experienced an increase in quality-adjusted life years at low additional cost from the anti-viral therapy and care.
Wayda et al’s model showed that the benefits of accepting Hepatitis C-positive hearts into the donor pool extend beyond the individual to the entire system. More hearts will be transplanted. Patients will be waitlisted for less time and fewer candidates will be bumped off the list. And, although there is an overall increase in cost of $124 million because more transplants would be performed, only 11% of that cost comes from the anti-viral therapy itself. Is $124 million a reasonable price? In the past, policy makers have used a standard of ‘$100k per quality-adjusted life year’ as the threshold to determine whether an intervention was cost-effective and worthwhile. At $82k/ quality-adjusted life year – Wayda et al’s simulation demonstrates that the benefits of allowing Hepatitis c-positive transplants outweigh the costs. Hospitals and policy-makers should strongly consider updating their protocols to allow transplanting of Hepatitis C-positive hearts and the saving of more lives.
Additional Stanford Cardiovascular Institute-affiliated authors who contributed to this study include Alexander T. Sandhu, Justin Parizo, and Jeffrey J. Teuteberg.