The cost effectiveness of implantable cardioverter-defibrillators: results from the Multicenter Automatic Defibrillator Implantation Trial (MADIT)-II.
OBJECTIVE
We sought to evaluate the cost implications of the implantable cardioverter-defibrillator (ICD), using utilization, cost, and survival data from the Multicenter Automatic Defibrillator Implantation Trial (MADIT)-II.


BACKGROUND
This trial showed that prophylactic implantation of a defibrillator reduces the rate of mortality in patients who experienced a previous myocardial infarction and low left ventricular ejection fraction. Given the size of the eligible population, the cost effectiveness of the ICD has substantial implications.


METHODS
Our research comprises the cost-effectiveness component of the randomized controlled trial, MADIT-II, based on utilization, cost, and survival information from 1,095 U.S. patients who were assigned randomly to receive an ICD or conventional medical care. Utilization data were converted to costs using a variety of national and hospital-specific data. The incremental cost-effectiveness ratio (iCER) was calculated as the difference in discounted costs divided by the difference in discounted life expectancy within 3.5 years. Secondary analyses included projections of survival (using three alternative assumptions), corresponding cost assumptions, and the resulting cost-effectiveness ratios until 12 years after randomization.


RESULTS
During the 3.5-year period of the study, the average survival gain for the defibrillator arm was 0.167 years (2 months), the additional costs were 39,200 dollars, and the iCER was 235,000 dollars per year-of-life saved. In three alternative projections to 12 years, this ratio ranged from 78,600 dollars to 114,000 dollars.


CONCLUSIONS
The estimated cost per life-year saved by the ICD in the MADIT-II study is relatively high at 3.5 years but is projected to be substantially lower over the course of longer time horizons.
Zwanziger
Jack
J
Department of Community and Preventive Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA. jzwanzig@uic.edu
Hall
W Jackson
WJ
Dick
Andrew W
AW
Zhao
Hongwei
H
Mushlin
Alvin I
AI
Hahn
Rebecca Marron
RM
Wang
Hongkun
H
Andrews
Mark L
ML
Mooney
Cathleen
C
Wang
Hongyue
H
Moss
Arthur J
AJ
D003362:Cost-Benefit Analysis; D017147:Defibrillators, Implantable / Q000191:economics*; D017048:Health Care Costs; D006801:Humans; D015337:Multicenter Studies as Topic; D016032:Randomized Controlled Trials as Topic; D016019:Survival Analysis