Background Eight randomized trials have evaluated whether theprophylactic use of an implantable cardioverterdefibrillator(ICD) improves survival among patients who are at risk for suddendeath due to left ventricular systolic dysfunction but who havenot had a life-threatening ventricular arrhythmia. We assessedthe cost-effectiveness of the ICD in the populations representedin these primary-prevention trials.
Methods We developed a Markov model of the cost, quality oflife, survival, and incremental cost-effectiveness of the prophylacticimplantation of an ICD, as compared with control therapy, amongpatients with survival and mortality rates similar to thosein each of the clinical trials. We modeled the efficacy of theICD as a reduction in the relative risk of death on the basisof the hazard ratios reported in the individual clinical trials.
Results Use of the ICD increased lifetime costs in every trial.Two trials the Coronary Artery Bypass Graft (CABG) PatchTrial and the Defibrillator in Acute Myocardial Infarction Trial(DINAMIT) found that the prophylactic implantation ofan ICD did not reduce the risk of death and thus was both moreexpensive and less effective than control therapy. For the othersix trials the Multicenter Automatic Defibrillator ImplantationTrial (MADIT) I, MADIT II, the Multicenter Unsustained TachycardiaTrial (MUSTT), the Defibrillators in Non-Ischemic CardiomyopathyTreatment Evaluation (DEFINITE) trial, the Comparison of MedicalTherapy, Pacing, and Defibrillation in Heart Failure (COMPANION)trial, and the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) the use of an ICD was projected to add between 1.01and 2.99 quality-adjusted life-years (QALY) and between $68,300and $101,500 in cost. Using base-case assumptions, we foundthat the cost-effectiveness of the ICD as compared with controltherapy in these six populations ranged from $34,000 to $70,200per QALY gained. Sensitivity analyses showed that this cost-effectivenessratio would remain below $100,000 per QALY as long as the ICDreduced mortality for seven or more years.
Conclusions Prophylactic implantation of an ICD has a cost-effectivenessratio below $100,000 per QALY gained in populations in whicha significant device-related reduction in mortality has beendemonstrated.
Source Information
From Duke Clinical Research Institute, Duke University, Durham, N.C. (G.D.S.); the Department of Health Research and Policy, School of Medicine (M.A.H.), and the Center for Primary Care and Outcomes Research, Department of Medicine (M.A.H., D.K.O.), Stanford University, Stanford, Calif.; and the Veterans Affairs Palo Alto Health Care System, Palo Alto, Calif. (D.K.O.).
Address reprint requests to Dr. Sanders at Duke Clinical Research Institute, P.O. Box 17969, Duke University, Durham, NC 27715, or at gillian.sanders{at}duke.edu.
Cost-Effectiveness of ICDs
Anderson K. P., Stevenson L. W., Stevenson W. G., Fauchier L., Babuty D., Sanders G. D., Hlatky M. A., Owens D. K.
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N Engl J Med 2006;
354:205-207, Jan 12, 2006.
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