(Circulation. 1996;93:489-496.)
© 1996 American Heart Association, Inc.
Articles |
Cost-effectiveness of Implantable Defibrillator as First-Choice Therapy Versus Electrophysiologically Guided, Tiered Strategy in Postinfarct Sudden Death Survivors
A Randomized Study
Presented in part at the 67th Scientific Sessions of the American Heart Association, Dallas, Tex, November 14-17, 1994, and published in abstract form in Circulation (1994;90[pt 2]:I-654).
From the Heart-Lung Institute (E.F.D.W., R.N.W.H., H.R., P.F.A.B., E.O.R. de M.), the Department of Health Sciences (G.S.), and the Clinical Epidemiology Unit (A.A.), University Hospital and University of Utrecht; the Department of Experimental Cardiology (F.J.L. van C.), and the Department of Epidemiology (J.G.P.T.), University Hospital and University of Amsterdam; the Thoraxcenter (H.J.G.M.C.), University Hospital and University of Groningen; and the Interuniversity Cardiology Institute of the Netherlands, Utrecht.
Correspondence to Eric F.D. Wever, MD, Department of Cardiology, Heart-Lung Institute, University Hospital Utrecht, 100 Heidelberglaan, PO Box 85500, 3508 GA Utrecht, Netherlands.
Background Rising costs of health care, partly as a result of costly therapeutic innovations, are of concern to both the medical profession and healthcare authorities. The implantable cardioverter-defibrillator (ICD) is still not remunerated by Dutch healthcare insurers. The aim of this study was to evaluate the cost-effectiveness of early implantation of the ICD in postinfarct sudden death survivors.
Methods and Results Sixty consecutive postinfarct survivors of cardiac arrest caused by ventricular tachycardia or fibrillation were randomly assigned either ICD as first choice (n=29) or a tiered therapy starting with antiarrhythmic drugs and guided by electrophysiological (EP) testing (n=31). Median follow-up was 729 days (range, 3 to 1675 days). Fifteen patients died, 4 in the early ICD group and 11 in the EP-guided strategy group (P=.07). For quantitative assessment, the cost-effectiveness ratio was calculated for both groups and expressed as median total costs per patient per day alive. Because effectiveness aspects other than mortality are not incorporated in this ratio, other factors related to quality of life were used as qualitative measures of cost-effectiveness. The cost-effectiveness ratios were $63 and $94 for the early ICD and EP-guided strategy groups, respectively, per patient per day alive. This amounts to a net cost-effectiveness of $11 315 per patient per year alive saved by early ICD implantation. Costs in the early ICD group were higher only during the first 3 months of follow-up, but as a result of the high proportion of therapy changes, including arrhythmia surgery and late ICD implantation, costs in the EP-guided strategy group became higher after that. Patients discharged with antiarrhythmic drugs as sole therapy had the lowest total costs. This subset, however, showed extremely high mortality, resulting in a poor cost-effectiveness ratio ($196 per day). Invasive therapies and hospitalization were the major contributors to costs. If quality-of-life measures are taken into account, the cost-effectiveness of early ICD implantation was even more favorable. Recurrent cardiac arrest and cardiac transplantation occurred in the EP-guided strategy group only, whereas exercise tolerance, total hospitalization duration, number of invasive procedures, and antiarrhythmic therapy changes were significantly in favor of early ICD implantation.
Conclusions In terms of cost-effectiveness, early ICD implantation is superior to the EP-guided therapeutic strategy in postinfarct sudden death survivors.
Key Words: death, sudden • cost-benefit analysis • defibrillation • electrophysiology • trials
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