Elsevier

American Heart Journal

Volume 144, Issue 3, September 2002, Pages 440-448
American Heart Journal

Final Reports from the AHRQ Sudden Death Patient Outcomes Research Team
Effect of risk stratification on cost-effectiveness of the implantable cardioverter defibrillator,☆☆,

https://doi.org/10.1067/mhj.2002.125501Get rights and content

Abstract

Background Implantable cardioverter defibrillators (ICDs) effectively prevent sudden cardiac death, but selection of appropriate patients for implantation is complex. We evaluated whether risk stratification based on risk of sudden cardiac death alone was sufficient to predict the effectiveness and cost-effectiveness of the ICD. Methods We developed a Markov model to evaluate the cost-effectiveness of ICD implantation compared with empiric amiodarone treatment. The model incorporated mortality rates from sudden and nonsudden cardiac death, noncardiac death and costs for each treatment strategy. We based our model inputs on data from randomized clinical trials, registries, and meta-analyses. We assumed that the ICD reduced total mortality rates by 25%, relative to use of amiodarone. Results The relationship between cost-effectiveness of the ICD and the total annual cardiac mortality rate is U-shaped; cost-effectiveness becomes unfavorable at both low and high total cardiac mortality rates. If the annual total cardiac mortality rate is 12%, the cost-effectiveness of the ICD varies from $36,000 per quality-adjusted life-year (QALY) gained when the ratio of sudden cardiac death to nonsudden cardiac death is 4 to $116,000 per QALY gained when the ratio is 0.25. Conclusions The cost-effectiveness of ICD use relative to amiodarone depends on total cardiac mortality rates as well as the ratio of sudden to nonsudden cardiac death. Studies of candidate diagnostic tests for risk stratification should distinguish patients who die suddenly from those who die nonsuddenly, not just patients who die suddenly from those who live. (Am Heart J 2002;144:440-8.)

Section snippets

Methods

We used a previously developed decision model to estimate the cost and benefits associated with use of an ICD or amiodarone.10 We examined 2 clinical strategies: use of an ICD alone or use of amiodarone alone. In previous analyses10 we found that a cross-over strategy that began with amiodarone and allowed subsequent implantation of an ICD for drug treatment failures was neither effective nor cost-effective; therefore, we did not include such a strategy. We used the perspective of society,

Results

Treatment with an ICD led to higher costs and longer life than did treatment with amiodarone. For example, at a total annual cardiac mortality rate of 12% and a ratio of sudden cardiac death to nonsudden cardiac death of 1.0, treatment with amiodarone resulted in expenditures of $82,000 and 4.39 QALYs. Treatment with ICD led to costs of $129,600 and 5.24 QALYs and an incremental cost of $54,700 per QALY gained. The cost-effectiveness of the ICD was influenced strongly by the total annual

Discussion

The purpose of our study was to assess how risk stratification could be used to identify patients for whom the ICD would be effective and cost-effective. Our main finding is that risk stratification strategies must provide information about both the likelihood of sudden and nonsudden cardiac death if they are to successfully identify patients for whom use of the ICD is economically attractive. In patients with high rates of sudden death but low rates of nonsudden cardiac death, the ICD provides

Acknowledgements

We thank Pinar Bilir for help with data analysis.

References (38)

  • A comparison of antiarrhythmic-drug therapy with implantable defibrillators in patients resuscitated from near-fatal ventricular arrhythmias: the Antiarrhythmics versus Implantable Defibrillators (AVID) Investigators

    N Engl J Med

    (1997)
  • SJ Connolly et al.

    Canadian Implantable Defibrillator Study (CIDS): study design and organization: CIDS Co-Investigators

    Am J Cardiol

    (1993)
  • KH Kuck et al.

    Randomized comparison of anti-arrhythmic drug therapy with implantable defibrillators in patients resuscitated from cardiac arrest: the Cardiac Arrest Study Hamburg (CASH)

    Circulation

    (2000)
  • AJ Moss et al.

    Improved survival with an implanted defibrillator in patients with coronary disease at high risk for ventricular arrhythmia: Multicenter Automatic Defibrillator Implantation Trial Investigators

    N Engl J Med

    (1996)
  • MADIT II, the Multi-center Autonomic Defibrillator Implantation Trial II stopped early for mortality reduction, has ICD therapy earned its evidence-based credentials?

    Int J Cardiol

    (2002)
  • AE Buxton et al.

    A randomized study of the prevention of sudden death in patients with coronary artery disease: Multicenter Unsustained Tachycardia Trial Investigators

    N Engl J Med

    (1999)
  • JT Bigger

    Prophylactic use of implanted cardiac defibrillators in patients at high risk for ventricular arrhythmias after coronary-artery bypass graft surgery: Coronary Artery Bypass Graft (CABG) Patch Trial Investigators

    N Engl J Med

    (1997)
  • DK Owens et al.

    Cost-effectiveness of implantable cardioverter defibrillators relative to amiodarone for prevention of sudden cardiac death

    Ann Intern Med

    (1997)
  • SJ Connolly et al.

    Meta-analysis of the implantable cardioverter defibrillator secondary prevention trials. AVID, CASH and CIDS studies: Antiarrhythmics vs Implantable Defibrillator study: Cardiac Arrest Study Hamburg: Canadian Implantable Defibrillator Study

    Eur Heart J

    (2000)
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    Supported in part by grant HS08362 from the Agency for Healthcare Research and Quality, Rockville, Md, and by Career Development Awards from the Department of Veterans Affairs Health Services Research and Development Office.

    ☆☆

    Reprint requests: Douglas K. Owens, MD, MS, VA Health Care System (111A), 3801 Miranda Ave, Palo Alto, CA 94304.

    E-mail:[email protected]

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