Cost-Effectiveness of Implantable Cardiac Devices

Study Questions:

What is the cost-effectiveness of implantable-cardioverter defibrillators (ICDs), cardiac resynchronization therapy pacemakers (CRT-Ps), and cardiac resynchronization therapy defibrillators (CRT-Ds)?

Methods:

Individual patient data from 13 randomized trials were pooled. A series of regression equations were used to predict baseline all-cause mortality, hospitalization rates, health-related quality of life, and device-related treatment effects. A UK National Health Service perspective and a lifetime time horizon were used. Benefits were expressed as quality-adjusted life-years (QALYs). Results were reported for 24 subgroups based on left bundle branch block (LBBB) status, QRS duration, and New York Heart Association (NYHA) class.

Results:

At a threshold of £30,000 per QALY gained, CRT-D was cost-effective in 10 of the 24 subgroups including all LBBB morphology patients with NYHA class I/II/III. ICD was cost-effective for all non-NYHA class IV patients with QRS duration <120 ms and for NYHA class I/II non-LBBB morphology patients with QRS duration between 120 ms and 149 ms. CRT-P was also cost-effective in all NYHA class III/IV patients with QRS duration >120 ms. Device therapy is cost-effective in most patient groups with LBBB at a threshold of £20,000 per QALY gained.

Conclusions:

The authors concluded that at a threshold of £30,000 per QALY gained, CRT-D is cost-effective in a far wider group than previously recommended in the UK. In some subgroups, ICDs and CRT-Ps remain the cost-effective choice.

Perspective:

The findings from this robust study were used to inform the British National Institute for Health and Care Excellence (NICE) guidelines, expanding them to a wider group of patients. Recent advances in average device longevity and a competitive device marketplace will further enhance cost-effectiveness.

Clinical Topics: Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Implantable Devices, EP Basic Science, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure, Chronic Heart Failure

Keywords: Arrhythmias, Cardiac, Bundle-Branch Block, Cardiac Resynchronization Therapy, Cost-Benefit Analysis, Defibrillators, Implantable, Heart Failure, Systolic, National Health Programs, Pacemaker, Artificial, Quality of Life, Quality-Adjusted Life Years


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