COST-EFFECTIVENESS OF CARDIAC RESYNCHRONIZATION THERAPY COMPARED WITH IMPLANTABLE CARDIOVERTER-DEFIBRILLATOR ALONE IN MILD HEART FAILURE

Tuesday, October 21, 2014
Poster Board # PS3-17

Candidate for the Lee B. Lusted Student Prize Competition

Allison Pitt, MS, Department of Management Science and Engineering, School of Engineering, Stanford University, Stanford, CA, Christopher Woo, MD, Department of Medicine, Division of Cardiovascular Medicine, School of Medicine, Stanford University, Stanford, CA, Erika Strandberg, MS, Department of Biomedical Informatics, School of Medicine, Stanford University, Stanford, CA, Michelle Schmiegelow, MD, Department of Health Research and Policy, School of Medicine, Stanford University, Stanford, CA, Mark A. Hlatky, MD, Departments of Medicine and Health Research and Policy, School of Medicine, Stanford University, Stanford, CA, Douglas K. Owens, MD, MS, Stanford Health Policy, Centers for Health Policy and Primary Care and Outcomes Research, Department of Medicine, Stanford University, Stanford, CA and Jeremy D. Goldhaber-Fiebert, PhD, Stanford University, Stanford Health Policy, Centers for Health Policy and Primary Care and Outcomes Research, Department of Medicine, Stanford, CA
Purpose:

   Heart failure constitutes a substantial and growing burden in the United States, with projected costs of $78 billion in 2030. Cardiac resynchronization therapy (CRT) improves outcomes in patients with mild heart failure, at additional expense, and its cost effectiveness in this population is unclear. We estimate the cost-effectiveness of CRT in addition to an implantable cardioverter-defibrillator (ICD), compared with ICD alone in patients with left ventricular systolic dysfunction, prolonged intraventricular conduction, and mild heart failure.

Methods:

   We developed a decision analytic Markov model to estimate the lifetime costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs) of CRT plus an ICD (CRT-D), as compared with ICD alone.  We modeled a hypothetical cohort of patients with clinical characteristics similar to those in the Multicenter Automatic Defibrillator Implantation Trial with Cardiac Resynchronization Therapy (MADIT-CRT) and Resynchronization-Defibrillation for Ambulatory Heart Failure Trial (RAFT) clinical trials, and performed the analysis from a societal perspective, discounting both costs and benefits at 3% annually.

Result:

   Compared to ICD, CRT-D increased life expectancy (9.8 years versus 8.8 years) and QALYs (8.4 years versus 7.5 years) at a cost of $57,800 ($286,100 versus $228,300), yielding an incremental cost-effectiveness ratio of $69,600 per QALY gained. The cost-effectiveness of CRT-D was most sensitive to the degree of its mortality benefit. If the all-cause mortality risk ratio of CRT-D compared to ICD was 0.9 (as opposed to 0.8 as reported in the RAFT trial), CRT-D cost $105,000 per QALY.  CRT-D device cost, battery life, and age at time of initial implantation also influenced the cost-effectiveness of CRT-D.  At an incremental CRT-D device cost of $15,000 (versus $7,000), CRT-DÕs cost per QALY gained was $100,000.  If CRT-D had a battery life of 3 years (versus 4 years), CRT-DÕs cost per QALY gained is $101,000.  The cost per QALY gained for CRT-D rose to $107,000 if the age at initial implantation was 80 years old (as opposed to 65 years old).

Conclusion:

   In patients with a left ventricular ejection fraction below 30%, QRS duration above 20 milliseconds, and NYHA class I-II symptoms, CRT-D provides reasonable value when a CRT-related reduction in mortality is evident.

See more of: POSTER SESSION III & CONTINENTAL BREAKFAST

See more of: The 36th Annual Meeting of the Society for Medical Decision Making