Cost-effectiveness of implantable cardiac devices in patients with systolic heart failure

Stuart Mealing, Bethan Sarah Woods, Neil Hawkins, Martin R. Cowie, Chris Plummer, William Abraham, John Beshai, Helmut Klein, Mark John Sculpher

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Objective: To evaluate the cost-effectiveness of implantable cardioverter-defibrillators (ICD), cardiac resynchronisation therapy pacemakers (CRT-P) and combination therapy (CRT-D) in patients with heart failure with reduced ejection fraction based on a range of clinical characteristics.   Methods: Individual patient data from 13 randomised trials were used to inform a decision analytic model. A series of regression equations were used to predict baseline all-cause mortality, hospitalisation rates and health related quality of life (HRQoL) and device-related treatment effects. Clinical variables used in these equations were age, QRS duration, NYHA class, ischemic aetiology, and LBBB. A UK NHS perspective and a lifetime time horizon were used. Benefits were expressed as quality adjusted life years (QALYs). Results were reported for 24 subgroups based on LBBB status, QRS duration and NYHA class.   Results: At a threshold of £30,000 per QALY gained, CRT-D was cost-effective in 10 of the 24 subgroups including all LBBB morphology patients with NYHA I/III/III. ICD is cost-effective for all non-NYHA IV patients with QRS duration <120ms and for NYHA I/II non-LBBB morphology patients with QRS duration between 120 and 149ms. CRT-P was also cost-effective in all NYHA III/IV patients with QRS duration >120ms. Device therapy is costeffective in most patient groups with LBBB at a threshold of £20,000 per QALY gained. Results were robust to altering key model parameters.    Conclusions: At a threshold of £30,000 per QALY gained, CRT-D is cost-effective in a far wider group than previously recommended in the UK. In some subgroups ICD and CRT-P remain the cost-effective choice.
Original languageEnglish
Number of pages46
Early online date13 Jul 2016
Publication statusE-pub ahead of print - 13 Jul 2016

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