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Arrhythmias |
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Title: The Cost Effectiveness of Implantable
Cardioverter-Defibrillators: Results From the Multicenter Automatic
Defibrillator Implantation Trial (MADIT)-II Department
of Community and Preventive Medicine, University of Rochester School of
Medicine and Dentistry, Rochester, New York, USA. |
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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. |
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Source |
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Content
provided by the American College of Cardiology Foundation |