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Benefits of Cardiac Resynchronization Therapy in an Asynchronous Heart Failure Model Induced by Left Bundle Branch Ablation and Rapid Pacing
Published on: December 11, 2017
Cost-effectiveness of cardiac resynchronization therapy in the MADIT-CRT trial
Katia Noyes1, Peter Veazie, William Jackson Hall
1Department of Community and Preventive Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York 14620, USA. katia_noyes@urmc.rochester.edu
Insights
Cardiac resynchronization therapy with an implantable cardioverter-defibrillator (CRT-ICD) is cost-effective for heart failure patients with left bundle branch block (LBBB). This therapy offers improved quality of life and survival benefits compared to an ICD alone.
Area of Science:
- Cardiology
- Health Economics
Background:
- The MADIT-CRT trial showed Cardiac Resynchronization Therapy (CRT) combined with an Implantable Cardiac Defibrillator (ICD) reduces heart failure events or death in specific patient groups.
- These patients typically have reduced ejection fraction and a wide QRS complex, often with left bundle branch block (LBBB).
Purpose of the Study:
- To assess the 4-year cost-effectiveness of CRT-ICD versus ICD alone using data from the MADIT-CRT trial.
- To perform sensitivity analyses based on age, gender, and LBBB status.
Main Methods:
- A randomized trial comparing ICD to CRT-ICD in a 2:3 ratio with up to 4-year follow-up.
- Cost-effectiveness analysis using healthcare utilization and health-related quality of life (HRQOL) data, measured by EQ-5D.
- Cost data derived from national Medicare reimbursement rates.
Main Results:
- Average 4-year healthcare costs were higher for CRT-ICD ($62,600) than for ICD alone ($57,050), primarily due to device and implantation expenses.
- The incremental cost-effectiveness ratio (ICER) for CRT-ICD was $58,330 per Quality-Adjusted Life Year (QALY) gained.
- Cost-effectiveness improved significantly for the LBBB subgroup ($7,320/QALY) and with a longer time horizon, showing no benefit for the non-LBBB group.
Conclusions:
- CRT-ICD is a cost-effective strategy compared to ICD-only in minimally symptomatic patients with low ejection fraction and LBBB within a 4-year timeframe.
- The LBBB subgroup demonstrates a favorable cost-effectiveness profile for CRT-ICD implantation.
Background:
The Multicenter Automatic Defibrillator Implantation Trial-Cardiac Resynchronization Therapy (MADIT-CRT) trial demonstrated that cardiac resynchronization therapy (CRT) when added to the implantable cardiac defibrillator (ICD) reduces risk of heart failure or death in minimally symptomatic patients with reduced cardiac ejection fraction and wide QRS complex.
Objectives:
To evaluate 4-year cost-effectiveness of CRT-ICD compared to ICD alone using MADIT-CRT data.
Research Design:
Patients enrolled in the trial were randomized to implantation of either ICD or CRT-ICD in a 2:3 ratio, with up to 4-year follow-up period. Cost-effectiveness analyses were conducted, and sensitivity analyses by age, gender, and left bundle branch block (LBBB) conduction pattern were performed.
Subjects:
A total of 1,271 patients with ICD or CRT-ICD (US centers only) who reported healthcare utilization and health-related quality of life data.
Measures:
We used the EQ-5D (US weights) to assess patient HRQOL and translated utilization data to costs using national Medicare reimbursement rates.
Results:
Average 4-year healthcare expenditures in CRT-ICD patients were higher than costs of ICD patients ($62,600 vs 57,050, P = 0.015), mainly due to the device and implant-related costs. The incremental cost-effectiveness ratio of CRT-ICD compared to ICD was $58,330/quality-adjusted life years (QALY) saved. The cost effectiveness improved with longer time horizon and for the LBBB subgroup ($7,320/QALY), with no cost-effectiveness benefit being evident in the non-LBBB group.
Conclusions:
In minimally symptomatic patients with low ejection fraction and LBBB, CRT-ICD is cost effective within 4-year horizon when compared to ICD-only.
