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	Full Text PDF PDA Full Text Supplementary Material Editorial by Goldman, L. Letters Add to Personal Archive Add to Citation Manager Notify a Friend E-mail When Cited E-mail When Letters Appear PubMed Citation

ABSTRACT

Background Eight randomized trials have evaluated whether the prophylactic use of an implantable cardioverter–defibrillator (ICD) improves survival among patients who are at risk for sudden death due to left ventricular systolic dysfunction but who have not had a life-threatening ventricular arrhythmia. We assessed the cost-effectiveness of the ICD in the populations represented in these primary-prevention trials.

Methods We developed a Markov model of the cost, quality of life, survival, and incremental cost-effectiveness of the prophylactic implantation of an ICD, as compared with control therapy, among patients with survival and mortality rates similar to those in each of the clinical trials. We modeled the efficacy of the ICD as a reduction in the relative risk of death on the basis of 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) Patch Trial and the Defibrillator in Acute Myocardial Infarction Trial (DINAMIT) — found that the prophylactic implantation of an ICD did not reduce the risk of death and thus was both more expensive and less effective than control therapy. For the other six trials — the Multicenter Automatic Defibrillator Implantation Trial (MADIT) I, MADIT II, the Multicenter Unsustained Tachycardia Trial (MUSTT), the Defibrillators in Non-Ischemic Cardiomyopathy Treatment Evaluation (DEFINITE) trial, the Comparison of Medical Therapy, 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 1.01 and 2.99 quality-adjusted life-years (QALY) and between $68,300 and $101,500 in cost. Using base-case assumptions, we found that the cost-effectiveness of the ICD as compared with control therapy in these six populations ranged from $34,000 to $70,200 per QALY gained. Sensitivity analyses showed that this cost-effectiveness ratio would remain below $100,000 per QALY as long as the ICD reduced mortality for seven or more years.

Conclusions Prophylactic implantation of an ICD has a cost-effectiveness ratio below $100,000 per QALY gained in populations in which a significant device-related reduction in mortality has been demonstrated.

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.

Full Text of this Article

Related Letters:

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. Correspondence

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