title: Cost-effectiveness of implantable cardioverter defibrillators relative to amiodarone for prevention of sudden cardiac death.
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.
  
  
  METHODS
  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.
  
  
  METHODS
  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.
authors.affiliation: Section of General Internal Medicine (111A), Veterans Affairs Palo Alto Health Care System, CA 94304, USA.
authors.forename: D K
authors.initials: DK
authors.lastname: Owens
authors.forename: G D
authors.initials: GD
authors.lastname: Sanders
authors.forename: R A
authors.initials: RA
authors.lastname: Harris
authors.forename: K M
authors.initials: KM
authors.lastname: McDonald
authors.forename: P A
authors.initials: PA
authors.lastname: Heidenreich
authors.forename: A D
authors.initials: AD
authors.lastname: Dembitzer
authors.forename: M A
authors.initials: MA
authors.lastname: Hlatky
mesh_terms: D000638:Amiodarone / Q000627:therapeutic use*; D000889:Anti-Arrhythmia Agents / Q000627:therapeutic use*; D003362:Cost-Benefit Analysis; D016757:Death, Sudden, Cardiac / Q000517:prevention & control*; D003663:Decision Trees; D017147:Defibrillators, Implantable / Q000191:economics*; D006801:Humans; D008390:Markov Chains; D008875:Middle Aged; D019057:Quality-Adjusted Life Years; D012307:Risk Factors
chemical_list: D000889:Anti-Arrhythmia Agents; D000638:Amiodarone