Long-term cost-effectiveness of alternative management strategies for patients with life-threatening ventricular arrhythmias. Electrophysiologic Study versus Electrocardiographic Monitoring (ESVEM) Investigators.
BACKGROUND
Serial antiarrhythmic drug testing guided by Holter monitoring and electrophysiologic study had similar clinical outcomes in the Electrophysiologic Study versus Electrocardiographic Monitoring (ESVEM) trial, while patients treated with sotalol had improved outcomes. The purpose of this study was to compare long-term cost-effectiveness of these management alternatives.


METHODS
Patients in the ESVEM trial were linked to computerized files of either the Health Care Finance Administration or the Department of Veterans Affairs. Total hospital costs and survival time over five year follow-up were measured using actuarial methods, and cost-effectiveness was calculated.


RESULTS
Patients randomized to therapy guided by electrophysiologic study had more hospital admissions, higher costs, and a cost-effectiveness ratio of $162,500 per life year added compared with therapy guided by Holter monitoring. Patients randomized to sotalol had fewer hospitalizations, lower costs, and better survival than patients randomized to other drugs, and sotalol was a dominant strategy in the cost-effectiveness analysis. Patients for whom an effective drug was found had fewer hospital admissions, lower costs, and longer survival. These findings were robust in sensitivity analyses and in bootstrap replications.


CONCLUSIONS
Serial drug testing guided by electrophysiologic study had an unfavorable cost-effectiveness ratio relative to Holter monitoring, while sotalol was cost-effective relative to other antiarrhythmic drugs.
Hlatky
M A
MA
Department of Health Research and Policy, Stanford University School of Medicine, California 94305-5092, USA.
Boothroyd
D B
DB
Johnstone
I M
IM
Marcus
F I
FI
Hahn
E
E
Hartz
V
V
Mason
J W
JW
D000368:Aged; D000889:Anti-Arrhythmia Agents / Q000191:economics / Q000627:therapeutic use*; D001145:Arrhythmias, Cardiac / Q000188:drug therapy* / Q000191:economics / Q000453:epidemiology; D003362:Cost-Benefit Analysis; D015716:Electrocardiography, Ambulatory; D004594:Electrophysiology; D005260:Female; D017721:Hospital Costs; D006760:Hospitalization; D006801:Humans; D008297:Male; D008875:Middle Aged; D016032:Randomized Controlled Trials as Topic; D012189:Retrospective Studies; D013015:Sotalol / Q000627:therapeutic use; D015996:Survival Rate; D013997:Time Factors
D000889:Anti-Arrhythmia Agents; D013015:Sotalol