Can implantable cardioverter-defibrillator therapy reduce healthcare costs?

This article presents a comparison of the costs and the cost effectiveness of defibrillator implantation in a hypothetical scenario for the years 1996-2000, with recently reported actual data from the Dutch prospective study over the years 1989-1993. Recently, technological advances in pulse generator and leads have revolutionized implantable cardioverter-defibrillator (ICD) therapy. Major advances include (1) transvenous single lead positioning and (2) tremendously reduced size, combined with prolonged longevity of the pulse generator. Both have simplified implantation technique and provided for superior effectiveness and lower costs. This suggests that a more favorable cost-effectiveness is to be expected. The study group reported here consisted of patients successfully resuscitated after cardiac arrest due to malignant ventricular tachyarrhythmias in the chronic stage of myocardial infarction. During a mean follow-up of 27 months, starting on the day of therapeutic decision making, total costs and the cost-effectiveness ratio were estimated. Actual data from the prospective study in 1989-1993 are compared with a hypothetical scenario for 1996-2000. Mortality and costs for hospitalization per day, per procedure, and per device are taken from the prospective study and equalized for both scenarios. Transthoracic lead positioning and abdominal implantation of a Ventak P (CPI) defibrillator with +/- 3 years longevity were characteristic of the recently completed prospective study. The hypothetical future scenario uses the Ventak Mini-2 with assumed 5 years longevity, implanted pectorally and connected to a single transvenous lead. Implantation will be carried out in the catheterization laboratory and as first-choice treatment. Due to prolonged longevity of the device and shorter hospitalization, a cost reduction of US $11,530 per patient is expected. Total costs per patient in the 1989-1993 prospective study in the (1) conventional arm (drugs first choice), (2) early ICD arm (ICD first choice), and (3) early ICD arm in the 1996-2000 study (ICD first choice) are $63,032, $56,067, and $44,537, respectively. The corresponding cost-effectiveness ratios are $87, $64, and $51 per day alive, respectively. Thus, it appears that modem ICD technology will be associated with an increasing reduction in healthcare costs, at least in selected patients. This reduction is associated with a more favorable cost-effectiveness ratio.