Final Reports from the AHRQ Sudden Death Patient Outcomes Research TeamEffect of risk stratification on cost-effectiveness of the implantable cardioverter defibrillator☆,☆☆,★
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.
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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.
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Reprint requests: Douglas K. Owens, MD, MS, VA Health Care System (111A), 3801 Miranda Ave, Palo Alto, CA 94304.
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E-mail:[email protected]