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7 September 2004 | Volume 141 Issue 5
Background: Heart failure is a common, costly, and debilitating illness. Resynchronization of ventricular contraction in patients with heart failure improves ejection fraction. The long-term morbidity and costs associated with such cardiac resynchronization therapy remain unclear.
Objective: To assess the incremental cost-effectiveness of cardiac resynchronization therapy.
Design: Markov model with Monte Carlo simulation. Future costs and effects were discounted at 3%.
Data Sources: Effects data were obtained from a concurrent systematic review. Health-related quality-of-life and cost data were obtained from publicly available data or from surveys.
Target Population: Patients with reduced ventricular function and prolonged QRS.
Time Horizon: Lifetime.
Perspective: U.S. health care system.
Interventions: Cardiac resynchronization therapy versus medical therapy.
Outcome Measures: Quality-adjusted life-years (QALYs), costs, and incremental cost-effectiveness.
Results of Base-Case Analysis: Medical therapy yielded a median of 2.64 (interquartile range, 2.47 to 2.82) discounted QALYs and a median discounted lifetime cost of $34 400 (interquartile range, $31 100 to $37 700). Cardiac resynchronization therapy was associated with a median incremental cost of $107 800 (interquartile range, $79 800 to $156 500) per additional QALY.
Results of Sensitivity Analysis: Results were sensitive to changes in several variables, including the relative risk for death or hospitalization.
Limitations: These results apply to patients who meet the inclusion criteria of the currently completed trials.
Conclusions: The incremental cost per QALY for cardiac resynchronization is similar to that of other commonly used interventions but is sensitive to changes in several key variables. Resynchronization therapy should not be considered in patients with comorbid illness that shortens life expectancy.
Editors' Notes
Context
Contribution
Cautions
–The Editors
Author and Article Information
From University of Washington–Harborview Prehospital Emergency Care Research and Training Center and Harborview Medical Center, Seattle, Washington; Ottawa Health Research Institute, University of Ottawa, Ottawa, Ontario, Canada; University of Alberta, Edmonton, Alberta, Canada; and Case Western Reserve University, Cleveland, Ohio.
See related article: Systematic Review: Cardiac Resynchronization in Patients with Symptomatic Heart Failure by F.A. McAlister, J.A. Ezekowitz, N. Wiebe, B. Rowe, C. Spooner, E. Crumley, L. Hartling, T. Klassen, and W. Abraham.
See editorial: Cardiac Resynchronization for Heart Failure by M.A. Hlatky and B.M. Massie.
Disclaimer: The authors of this manuscript are responsible for its contents, including any clinical or treatment recommendations. No statement in this article should be construed as an endorsement by or an official position of the Agency for Healthcare Research and Quality, the U.S. Department of Health and Human Services, or the Heart and Stroke Foundation.
Acknowledgments: The authors thank Drs. David Atkins and Donald E. Casey Jr., who reviewed a draft of this work for the Agency for Healthcare Research and Quality, for their advice.
Grant Support: This research was conducted by the University of Alberta Evidence-based Practice Center under contract to the Agency for Healthcare Research and Quality (contract no. 290-02-0023). Additional support was provided by the Heart and Stroke Foundation of Canada (grant no. NA4443).
Potential Financial Conflicts of Interest: Grants received: G. Nichol (Medtronic of Canada, Medtronic, Inc., Guidant Corp., Canadian Institutes of Health Research).
Requests for Single Reprints: Graham Nichol, MD, University of Washington–Harborview Prehospital Emergency Care Research and Training Center, Harborview Medical Center, 325 Ninth Avenue, Box 359747, Seattle, WA 98104; e-mail, nichol{at}u.washington.edu.
Current Author Addresses: Dr. Nichol: University of Washington–Harborview Prehospital Research and Training Center, Harborview Medical Center, 325 Ninth Avenue, Box 359747, Seattle, WA 98104.
Dr. Kaul: Department of Medicine, University of Alberta, 7221 Aberhart Center—I, 8440 112 Street, Edmonton, Alberta T6G 2B7, Canada.
Ms. Huszti: Ottawa Health Research Institute, 1053 Carling Avenue, Ottawa, Ontario K1Y 4E9, Canada.
Dr. Bridges: Department of Epidemiology and Biostatistics, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH 44106-4945.
Author Contributions: Conception and design: G. Nichol.
Analysis and interpretation of the data: G. Nichol, E. Huszti, J.F.P. Bridges.
Drafting of the article: G. Nichol, J.F.P. Bridges.
Critical revision of the article for important intellectual content: E. Huszti.
Final approval of the article: G. Nichol, P. Kaul, E. Huszti.
Provision of study materials or patients: G. Nichol.
Statistical expertise: E. Huszti, J.F.P. Bridges.
Obtaining of funding: G. Nichol.
Administrative, technical, or logistic support: G. Nichol.
Collection and assembly of data: G. Nichol, P. Kaul, J.F.P. Bridges. ARTICLE
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