Cost-effectiveness of defibrillator therapy or amiodarone in chronic stable heart failure: results from the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT).
BACKGROUND
In the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT), implantable cardioverter-defibrillator (ICD) therapy significantly reduced all-cause mortality rates compared with medical therapy alone in patients with stable, moderately symptomatic heart failure, whereas amiodarone had no benefit on mortality rates. We examined long-term economic implications of these results.


RESULTS
Medical costs were estimated by using hospital billing data and the Medicare Fee Schedule. Our base case cost-effectiveness analysis used empirical clinical and cost data to estimate the lifetime incremental cost of saving an extra life-year with ICD therapy relative to medical therapy alone. At 5 years, the amiodarone arm had a survival rate equivalent to that of the placebo arm and higher costs than the placebo arm. For ICD relative to medical therapy alone, the base case lifetime cost-effectiveness and cost-utility ratios (discounted at 3%) were dollar 38,389 per life-year saved (LYS) and dollar 41,530 per quality-adjusted LYS, respectively. A cost-effectiveness ratio < dollar 100,000 was obtained in 99% of 1000 bootstrap repetitions. The cost-effectiveness ratio was sensitive to the amount of extrapolation beyond the empirical 5-year trial data: dollar 127,503 per LYS at 5 years, dollar 88,657 per LYS at 8 years, and dollar 58,510 per LYS at 12 years. Because of a significant interaction between ICD treatment and New York Heart Association class, the cost-effectiveness ratio was dollar 29,872 per LYS for class II, whereas there was incremental cost but no incremental benefit in class III.


CONCLUSIONS
Prophylactic use of single-lead, shock-only ICD therapy is economically attractive in patients with stable, moderately symptomatic heart failure with an ejection fraction < or = 35%, particularly those in NYHA class II, as long as the benefits of ICD therapy observed in the SCD-HeFT persist for at least 8 years.
Mark
Daniel B
DB
Outcomes Research Group, Duke Clinical Research Institute, PO Box 17969, Durham, NC 27715, USA. daniel.mark@duke.edu
Nelson
Charlotte L
CL
Anstrom
Kevin J
KJ
Al-Khatib
Sana M
SM
Tsiatis
Anastasios A
AA
Cowper
Patricia A
PA
Clapp-Channing
Nancy E
NE
Davidson-Ray
Linda
L
Poole
Jeanne E
JE
Johnson
George
G
Anderson
Jill
J
Lee
Kerry L
KL
Bardy
Gust H
GH
D000328:Adult; D003362:Cost-Benefit Analysis; D016757:Death, Sudden, Cardiac / Q000453:epidemiology; D017147:Defibrillators, Implantable / Q000191:economics*; D004597:Electroshock; D004867:Equipment Design; D006333:Heart Failure / Q000601:surgery*; D006801:Humans; D008499:Medical Records; D016032:Randomized Controlled Trials as Topic / Q000191:economics; D012189:Retrospective Studies; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology