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Cost-effectiveness of implantable defibrillator as first-choice therapy versus electrophysiologically guided, tiered
E F Wever1, R N Hauer, G Schrijvers
1Heart-Lung Institute, University Hospital, University of Utrecht, Netherlands.
Insights
Early implantable cardioverter-defibrillator (ICD) implantation is more cost-effective than electrophysiological (EP)-guided therapy for sudden cardiac death survivors. This strategy improves quality of life and reduces long-term healthcare costs.
Area of Science:
- Cardiology
- Health Economics
Background:
- Rising healthcare costs are a global concern, particularly for expensive innovations like implantable cardioverter-defibrillators (ICDs).
- Dutch healthcare insurers do not yet reimburse ICDs, necessitating cost-effectiveness evaluations.
Purpose of the Study:
- To evaluate the cost-effectiveness of early ICD implantation versus an electrophysiological (EP)-guided strategy in survivors of sudden cardiac death post-myocardial infarction.
Main Methods:
- A randomized trial comparing early ICD implantation (n=29) with a tiered therapy approach (antiarrhythmic drugs and EP testing, n=31) in 60 post-infarct survivors.
- Cost-effectiveness was assessed using median total costs per patient per day alive and qualitative measures including quality of life.
Main Results:
- The early ICD group demonstrated a favorable cost-effectiveness ratio ($63/patient/day alive) compared to the EP-guided group ($94/patient/day alive).
- Early ICD implantation resulted in a net cost-effectiveness of $11,315 per year of life saved.
- The EP-guided strategy incurred higher long-term costs due to therapy changes, including surgery and late ICD implantation.
Conclusions:
- Early ICD implantation is superior to the EP-guided therapeutic strategy for post-infarct sudden death survivors in terms of cost-effectiveness.
- Early ICD implantation also showed advantages in quality-of-life measures, including exercise tolerance and reduced hospitalization.
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.