Title: The Cost Effectiveness of Implantable Cardioverter-Defibrillators: Results From the Multicenter Automatic Defibrillator Implantation Trial (MADIT)-II
Topic: Arrhythmias
Date Posted: 6/20/2006
Author(s): Zwanziger J, Hall WJ, Dick AW, et al.

Department of Community and Preventive Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA.
J Am Coll Cardiol. 2006;47:2310-2318.
Clinical Trial: No

Study Question: How cost-effective is the implantable cardioverter defibrillator (ICD) when used for 1 prevention in post-infarction patients?

Methods: The total cost of health care during 3.5 years of follow-up was determined in 1,095 patients in the MADIT-II study who were randomized to the ICD arm (n=664) or the control group (n=431). All patients had a history of myocardial infarction and an ejection fraction ≤0.30. Survival data from MADIT-II were used to calculate the incremental cost-effectiveness ratio (ICER). Survival was projected out to 12 years to allow calculation of long-term ICERs.

Results: Compared to the control group, the total cost of health care at 3.5 years was $39,200 greater and life expectancy was two months longer in the ICD arm. This yielded an ICER of $235,000 per year-of-life saved. When projected out to 12 years of follow-up, the ICER ranged from $78,600 to $114,000, depending on the assumptions used in the model.

Conclusions: The cost of ICDs per year-of-life saved is high in MADIT-II-type patients, particularly during the initial 3.5 years of follow-up.

Perspective: An ICER near $60,000 per year-of-life saved generally is considered favorable. Therefore, an ICER of $235,000 indicates that the cost-effectiveness of the ICD is highly unfavorable in MADIT-II-type patients. This is because mortality was improved by the ICD by only 7% at three years of follow-up in the MADIT-II trial, necessitating ICD implantation in 14 patients to save one life. Available data suggest that microvolt T wave alternans testing can significantly improve cost-effectiveness by identifying approximately one-third of MADIT-II-type patients who are at very low risk of death during two years of follow-up and may not require an ICD.  Fred Morady, M.D., F.A.C.C.




Content provided by the American College of Cardiology Foundation