title: Cost-effectiveness of implantable cardioverter-defibrillators in Brazil: primary prevention analysis in the public sector.
abstract: BACKGROUND
  Several studies have demonstrated the effectiveness and cost-effectiveness of implantable cardioverter-defibrillators (ICDs) in chronic heart failure (CHF) patients. Despite its widespread use in developing countries, limited data exist on its cost-effectiveness in these settings.
  
  
  OBJECTIVE
  To evaluate the cost-effectiveness of ICD in CHF patients under the perspective of the Brazilian Public Healthcare System (PHS).
  
  
  METHODS
  We developed a Markov model to evaluate the incremental cost-effectiveness ratio (ICER) of ICD compared with conventional therapy in patients with CHF and New York Heart Association class II and III. Effectiveness was evaluated in quality-adjusted life years (QALYs) and time horizon was 20 years. We searched MEDLINE for clinical trials and cohort studies to estimate data from effectiveness, complications, mortality, and utilities. Costs from the PHS were retrieved from national administrative databases. The model's robustness was assessed through Monte Carlo simulation and one-way sensitivity analysis. Costs were expressed as international dollars, applying the purchasing power parity conversion rate (PPP US$).
  
  
  RESULTS
  ICD therapy was more costly and more effective, with incremental cost-effectiveness estimates of PPP US$ 50,345/QALY. Results were more sensitive to costs related to the device, generator replacement frequency and ICD effectiveness. In a simulation resembling the MADIT-I population survival and ICD benefit, the ICER was PPP US$ 17,494/QALY and PPP US$ 15,394/life years.
  
  
  CONCLUSIONS
  In a Brazilian scenario, where ICD cost is proportionally more elevated than in developed countries, ICD therapy was associated with a high cost-effectiveness ratio. The results were more favorable for a patient subgroup at increased risk of sudden death.
authors.affiliation: Graduate Program in Epidemiology of Universidade Federal do Rio Grande do Sul, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil.
authors.forename: Rodrigo Antonini
authors.initials: RA
authors.lastname: Ribeiro
authors.forename: Steffan Frosi
authors.initials: SF
authors.lastname: Stella
authors.forename: Suzi Alves
authors.initials: SA
authors.lastname: Camey
authors.forename: Leandro Ioschpe
authors.initials: LI
authors.lastname: Zimerman
authors.forename: Maurício
authors.initials: M
authors.lastname: Pimentel
authors.forename: Luis Eduardo
authors.initials: LE
authors.lastname: Rohde
authors.forename: Carísi Anne
authors.initials: CA
authors.lastname: Polanczyk
mesh_terms: D001938:Brazil; D003362:Cost-Benefit Analysis; D016757:Death, Sudden, Cardiac / Q000209:etiology / Q000517:prevention & control*; D003663:Decision Trees; D017147:Defibrillators, Implantable / Q000191:economics*; D006333:Heart Failure / Q000150:complications / Q000191:economics* / Q000628:therapy*; D006801:Humans; D008390:Markov Chains; D008875:Middle Aged; D009010:Monte Carlo Method; D011322:Primary Prevention / Q000191:economics*; D011634:Public Health / Q000191:economics; D017150:Public Sector / Q000191:economics; D019057:Quality-Adjusted Life Years; D016019:Survival Analysis