Should the implantable cardiac defibrillator be used for primary prevention of sudden death? A review of the issues relevant to hospital decision making.
BACKGROUND
New evidence suggests that the implantable cardiac defibrillator (ICD) may be effective for primary prevention of sudden death. High instrumental cost and the potentially large number of candidates will significantly impact hospital budgets.


OBJECTIVE
To review the information relevant to hospital policy decisions on the use of ICDs for primary prevention.


METHODS
Modelling based on an evaluation of reported studies and Canadian costs, detailed in a comprehensive review available at <http://upload.mcgill.ca/tau/icd.pdf>.


RESULTS
Health outcomes: Two high-quality primary prevention trials suggest a reduction in annual mortality of 2.9% with bounds of probability (PB) of 2.0% to 3.8%, in early years. To undertake 100 implants per year may result in an increasing annual saving of life-years of acceptable quality, stabilizing by 15 years at 110 (PB 72 to 154) each year. Economic impact: The annual costs would stabilize at 15 years at approximately 4.3 million dollars. Cost-effectiveness: The incremental cost-effectiveness from the point of view of the health care system would be approximately 47,000 dollars (PB 35,000 dollars to 70,000 dollars), discounted at 3%. Ethical and legal issues: The decision should not be individual but institutional, using a process that is transparent, consistent and fair.


CONCLUSIONS
The ICD can prolong life, with acceptable quality. Restriction of its use would be solely on grounds of expense.
McGregor
Maurice
M
The McGill University Health Centre, Montreal, Quebec, Canada. maurice.mcgregor@mcgill.ca
Chen
Jun
J
D002017:Budgets; D003362:Cost-Benefit Analysis; D003645:Death, Sudden / Q000517:prevention & control*; D003659:Decision Making, Organizational; D017147:Defibrillators, Implantable / Q000191:economics / Q000706:statistics & numerical data*; D004991:Ethics, Institutional; D005260:Female; D006739:Hospital Administration / Q000191:economics / Q000941:ethics; D017721:Hospital Costs; D006801:Humans; D008297:Male; D016134:Organizational Policy; D011322:Primary Prevention / Q000191:economics / Q000379:methods*; D011788:Quality of Life; D011792:Quebec; D018570:Risk Assessment; D013673:Technology Assessment, Biomedical / Q000191:economics / Q000941:ethics