Cost-Effectiveness of CRT in Mild Heart Failure

Study Questions:

What is the cost-effectiveness of adding cardiac resynchronization therapy (CRT) to an implantable cardioverter-defibrillator (CRT-D) compared with implantable cardioverter-defibrillator (ICD) alone among patients with prolonged intraventricular conduction and mild systolic heart failure (HF)?

Methods:

The study cohort was comprised of HF patients ages ≥65 years with a left ventricular ejection fraction (LVEF) of ≤30%, QRS duration of ≥120 ms, and New York Heart Association (NYHA) class I or II symptoms. The data were obtained from clinical trials, clinical registries, claims data from Centers for Medicare & Medicaid Services, and Centers for Disease Control and Prevention life tables. The authors compared CRT-D or ICD, alone using the Markov decision model, life-years, quality-adjusted life-years (QALYs), costs, and incremental cost-effectiveness ratios (ICERs). They performed base-case analyses and one- and two-way deterministic sensitivity case analyses on the data set.

Results:

The base-case analyses found that use of CRT-D increased life expectancy (9.8 years vs. 8.8 years), QALYs (8.6 years vs. 7.6 years), and costs ($286,500 vs. $228,600), yielding a cost per QALY gained of $61,700. The sensitivity analyses found that the cost-effectiveness of CRT-D was most dependent on the degree of mortality reduction: When the risk ratio for death was 0.95, the ICER increased to $119,600 per QALY. The cost-effectiveness of CRT-D was less favorable when expensive CRT-D devices were implanted, with shorter CRT-D battery life, and when implanted at an older age.

Conclusions:

The authors concluded that in patients with an LVEF of ≤30%, QRS duration of ≥120 ms, and NYHA class II symptoms, CRT-D appears to be economically attractive relative to ICD alone when a reduction in mortality is expected.

Perspective:

This is an important study because it suggests that CRT-D with ICD is cost-effective in patients with NYHA class II systolic HF. However, the estimated reduction in mortality was based on a single trial. Also the data were not sufficient to come to a conclusion in patients with NYHA class I HF. More studies are required to confirm the findings of this analysis.


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