Cost-effectiveness of a microvolt T-wave alternans screening strategy for implantable cardioverter-defibrillator placement in the MADIT-II-eligible population.
OBJECTIVE
This study was designed to compare the cost-effectiveness of implantable cardioverter-defibrillator (ICD) placement with and without risk stratification with microvolt T-wave alternans (MTWA) testing in the MADIT-II (Second Multicenter Automatic Defibrillator Implantation Trial) eligible population.


BACKGROUND
Implantable cardioverter-defibrillators have been shown to prevent mortality in the MADIT-II population. Microvolt T-wave alternans testing has been shown to be effective in risk stratifying MADIT-II-eligible patients.


METHODS
On the basis of published data, cost-effectiveness of three therapeutic strategies in MADIT-II-eligible patients was assessed using a Markov model: 1) ICD placement in all; 2) ICD placement in patients testing MTWA non-negative;, and 3) medical management. Outcomes of expected cost, quality-adjusted life-years (QALYs), and incremental cost-effectiveness were determined for patient lifetime.


RESULTS
Under base-case assumptions, providing ICDs only to those who test MTWA non-negative produced a gain of 1.14 QALYs at an incremental cost of 55,700 dollars when compared to medical therapy, resulting in an incremental cost-effectiveness ratio (ICER) of 48,700 dollars/QALY. When compared with a MTWA risk-stratification strategy, placing ICDs in all patients resulted in an ICER of 88,700 dollars/QALY. Most (83%) of the potential benefit was achieved by implanting ICDs in the 67% of patients who tested MTWA non-negative. Results were most sensitive to the effectiveness of MTWA as a risk-stratification tool, MTWA negative screen rate, cost and efficacy of ICD therapy, and patient risk for arrhythmic death.


CONCLUSIONS
Risk stratification with MTWA testing in MADIT-II-eligible patients improves the cost-effectiveness of ICDs. Implanting defibrillators in all MADIT-II-eligible patients, however, is not cost-effective, with one-third of patients deriving little additional benefit at great expense.
Chan
Paul S
PS
VA Center for Practice Management and Outcomes Research, Ann Arbor, Michigan, USA. paulchan@umich.edu
Stein
Kenneth
K
Chow
Theodore
T
Fendrick
Mark
M
Bigger
J Thomas
JT
Vijan
Sandeep
S
D000368:Aged; D003362:Cost-Benefit Analysis; D016757:Death, Sudden, Cardiac / Q000517:prevention & control*; D003661:Decision Support Techniques; D017147:Defibrillators, Implantable / Q000009:adverse effects / Q000191:economics*; D022062:Electrophysiologic Techniques, Cardiac / Q000191:economics*; D004608:Eligibility Determination; D006801:Humans; D008390:Markov Chains; D008484:Medicaid; D006278:Medicare; D017202:Myocardial Ischemia / Q000191:economics / Q000628:therapy; D019057:Quality-Adjusted Life Years; D018570:Risk Assessment; D014481:United States; D018487:Ventricular Dysfunction, Left / Q000191:economics / Q000628:therapy