This presentation is part of: Poster Session - CEA: Methods and Applications; Health Services Research
COST EFFECTIVENESS OF THE IMPLANTABLE CARDIOVERTER DEFIBRILLATOR IN THE MADIT-II POPULATION
Gillian D. Sanders, PhD, Duke, Medicine, Durham, NC, Mark A Hlatky, MD, Stanford University, Health Research and Policy, Stanford, CA, and Douglas K. Owens, MD, MS, Stanford University, Medicine, Stanford, CA.
The Multicenter Automatic Defibrillator Implantation Trial (MADIT)-II randomized clinical trial demonstrated implantable cardioverter defibrillators (ICDs) improve survival in post myocardial infarction patients with low ejection fraction. We evaluated the cost effectiveness of ICD implantation compared with conventional therapy in such a population. We used a Markov-model based cost-effectiveness analysis to estimate the lifetime costs, life expectancy, quality-adjusted life expectancy, and incremental cost effectiveness. We based survival, sudden cardiac death, and the effectiveness of the ICD on the MADIT-II trial population, and used costs and utilities from the published literature. Total mortality was assumed to be composed of three types: sudden cardiac, non-sudden cardiac, and non-cardiac mortality. Assuming an exponential declining life expectancy, we modeled a constant probability of sudden and non-sudden cardiac death to match the trial sudden and total mortalities for conventional treatment over the average trial follow up (20 months). Based on the trial data we assumed a 67% relative risk reduction in sudden cardiac death in the ICD arm. Compared with conventional therapy, over a patient's lifetime, ICD use led to a greater quality-adjusted life expectancy (increase of 1.33 QALYs) but higher costs (increase of $67,900) - resulting in an incremental cost effectiveness of $50,900/QALY gained compared with conventional therapy. To obtain a cost-effectiveness of less than $100,000/QALY, ICDs must reduce arrhythmic mortality by 31.2%. If the cost of the ICD device were reduced from $25,000 to $10,000, the incremental cost effectiveness of the ICD relative to conventional therapy would improve from $50,900 to $33,500/QALY gained. If the ICD improved quality of life, the cost effectiveness is more favorable than our base-case estimate; however if quality of life is substantially diminished, use of an ICD becomes expensive. There is little evidence to suggest such an effect on quality of life, however. Our analysis indicates that use of an ICD in patients who meet the criteria for the MADIT-II trial may be economically favorable when compared with conventional therapy. The size of population potentially eligible for prophylactic ICD implantation however suggests that future studies may identify large subgroups in whom the cost-effectiveness of prophylactic ICD implantation is higher or lower than the average for this clinical population.
