title: Wearable cardioverter-defibrillator for prevention of sudden cardiac death after infected implantable cardioverter-defibrillator removal: A cost-effectiveness evaluation.
abstract: BACKGROUND
  Prevention of sudden cardiac arrest (SCA) after removal of an infected implantable cardioverter-defibrillator (ICD) is a challenging clinical dilemma. The cost-effectiveness of the wearable cardioverter-defibrillator (WCD) in this setting remains uncertain.
  
  
  OBJECTIVE
  The purpose of this study was to compare the cost-effectiveness of the WCD with discharge home, discharge to a skilled nursing facility, or inpatient monitoring for the prevention of SCA after infected ICD removal.
  
  
  METHODS
  A decision model was developed to compare the cost-effectiveness of use of the WCD to several different strategies for patients who undergo ICD removal. One-way and 2-way sensitivity analyses were performed to account for uncertainties.
  
  
  RESULTS
  In the base-case analysis, the incremental cost-effectiveness of the WCD strategy was $20,300 per life-year (LY) or $26,436 per quality-adjusted life-year (QALY) compared to discharge home without a WCD. Discharge to a skilled nursing facility and in-hospital monitoring resulted in higher costs and worse clinical outcomes. The incremental cost-effectiveness ratio was as low as $15,392/QALY if the WCD successfully terminated 95% of SCA events and exceeded the $50,000/QALY willingness-to-pay threshold if the efficacy was <69%.The WCD strategy remained cost-effective, assuming 5.6% 2-month SCA risk, as long as the time to reimplantation was at least 2 weeks.
  
  
  CONCLUSIONS
  The WCD likely is cost-effective in protecting patients against SCA after infected ICD removal while waiting for ICD reimplantation compared to keeping patients in the hospital or discharging them home or to a skilled nursing facility.
authors.affiliation: Division of Cardiology, University of Miami Miller School of Medicine, Miami, Florida. Electronic address: healycr@gmail.com.
authors.forename: Christopher A
authors.initials: CA
authors.lastname: Healy
authors.affiliation: Division of Cardiothoracic Surgery, University of Miami Miller School of Medicine, Miami, Florida.
authors.forename: Roger G
authors.initials: RG
authors.lastname: Carrillo
mesh_terms: D003362:Cost-Benefit Analysis; D016757:Death, Sudden, Cardiac / Q000209:etiology / Q000517:prevention & control*; D003661:Decision Support Techniques; D047548:Defibrillators / Q000191:economics*; D017147:Defibrillators, Implantable / Q000009:adverse effects / Q000191:economics; D020878:Device Removal / Q000009:adverse effects / Q000191:economics / Q000379:methods / Q000401:mortality; D006801:Humans; D010043:Outcome and Process Assessment, Health Care; D010346:Patient Care Management / Q000191:economics / Q000379:methods; D010351:Patient Discharge / Q000191:economics*; D016459:Prosthesis-Related Infections / Q000209:etiology / Q000601:surgery*; D018570:Risk Assessment; D014481:United States
keywords: Cardiac implantable electronic device; Device extraction; Device infection; Implantable cardioverter-defibrillator; Wearable cardioverter-defibrillator