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

Ann Intern Med. 1997 Jan 1;126(1):1-12. doi: 10.7326/0003-4819-126-1-199701010-00001.

Abstract

Background: Implantable cardioverter defibrillators (ICDs) are remarkably effective in terminating ventricular arrhythmias, but they are expensive and the extent to which they extend life is unknown. The marginal cost-effectiveness of ICDs relative to amiodarone has not been clearly established.

Objective: To compare the cost-effectiveness of a third-generation implantable ICD with that of empirical amiodarone treatment for preventing sudden cardiac death in patients at high or intermediate risk.

Design: A Markov model was used to evaluate health and economic outcomes of patients who received an ICD, amiodarone, or a sequential regimen that reserved ICD for patients who had an arrhythmia during amiodarone treatment.

Measurements: Life-years gained, quality-adjusted life-years gained, costs, and marginal cost-effectiveness.

Results: For the base-case analysis, it was assumed that treatment with an ICD would reduce the total mortality rate by 20% to 40% at 1 year compared with amiodarone and that the ICD generator would be replaced every 4 years. In high-risk patients, if an ICD reduces total mortality by 20%, patients who receive an ICD live for 4.18 quality-adjusted life-years and have a lifetime expenditure of $88,400. Patients receiving amiodarone live for 3.68 quality-adjusted life-years and have a lifetime expenditure of $51,000. Marginal cost-effectiveness of an ICD relative to amiodarone is $74,400 per quality-adjusted life-year saved. If an ICD reduces mortality by 40%, the cost-effectiveness of ICD use is $37,300 per quality-adjusted life-year saved. Both choice of therapy (an ICD or amiodarone) and the cost-effectiveness ratio are sensitive to assumptions about quality of life.

Conclusions: Use of an ICD will cost more than $50,000 per quality-adjusted life-year gained unless it reduces all-cause mortality by 30% or more relative to amiodarone. Current evidence does not definitively support or exclude a benefit of this magnitude, but ongoing randomized trials have sufficient statistical power to do so.

Publication types

  • Comparative Study
  • Research Support, U.S. Gov't, Non-P.H.S.
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Amiodarone / therapeutic use*
  • Anti-Arrhythmia Agents / therapeutic use*
  • Cost-Benefit Analysis
  • Death, Sudden, Cardiac / prevention & control*
  • Decision Trees
  • Defibrillators, Implantable / economics*
  • Humans
  • Markov Chains
  • Middle Aged
  • Quality-Adjusted Life Years
  • Risk Factors

Substances

  • Anti-Arrhythmia Agents
  • Amiodarone