title: Cost-Effectiveness Analysis of Quadripolar Versus Bipolar Left Ventricular Leads for Cardiac Resynchronization Defibrillator Therapy in a Large, Multicenter UK Registry.
abstract: The objective of this study was to evaluate the cost-effectiveness of quadripolar versus bipolar cardiac resynchronization defibrillator therapy systems.
  
  
  
  Quadripolar left ventricular (LV) leads for cardiac resynchronization therapy reduce phrenic nerve stimulation (PNS) and are associated with reduced mortality compared with bipolar leads.
  
  
  
  A total of 606 patients received implants at 3 UK centers (319 Q, 287 B), between 2009 and 2014; mean follow-up was 879 days. Rehospitalization episodes were costed at National Health Service national tariff rates, and EQ-5D utility values were applied to heart failure admissions, acute coronary syndrome events, and mortality data, which were used to estimate quality-adjusted life-year differences over 5 years.
  
  
  
  Groups were matched with regard to age and sex. Patients with quadripolar implants had a lower rate of hospitalization than those with bipolar implants (42.6% vs. 55.4%; p = 0.002). This was primarily driven by fewer hospital readmissions for heart failure (51 [16%] vs. 75 [26.1%], respectively, for quadripolar vs. bipolar implants; p = 0.003) and generator replacements (9 [2.8%] vs. 19 [6.6%], respectively; p = 0.03). Hospitalization for suspected acute coronary syndrome, arrhythmia, device explantation, and lead revisions were similar. This lower health-care utilization cost translated into a cumulative 5-year cost saving for patients with quadripolar systems where the acquisition cost was <£932 (US $1,398) compared with bipolar systems. Probabilistic sensitivity analysis results mirrored the deterministic calculations. For the average additional price of £1,200 (US $1,800) over a bipolar system, the incremental cost-effective ratio was £3,692 per quality-adjusted life-year gained (US $5,538), far below the usual willingness-to-pay threshold of £20,000 (US $30,000).
  
  
  
  In a UK health-care 5-year time horizon, the additional purchase price of quadripolar cardiac resynchronization defibrillator therapy systems is largely offset by lower subsequent event costs up to 5 years after implantation, which makes this technology highly cost-effective compared with bipolar systems.
authors.affiliation: Imaging Sciences & Biomedical Engineering, King's College London, London, United Kingdom; Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom.
authors.forename: Jonathan M
authors.initials: JM
authors.lastname: Behar
authors.affiliation: Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom.
authors.forename: Hui Men Selina
authors.initials: HM
authors.lastname: Chin
authors.affiliation: St. Jude Medical, Stratford Upon Avon, United Kingdom.
authors.forename: Steve
authors.initials: S
authors.lastname: Fearn
authors.affiliation: Oxford Heart Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom.
authors.forename: Julian O M
authors.initials: JO
authors.lastname: Ormerod
authors.affiliation: Oxford Heart Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom.
authors.forename: James
authors.initials: J
authors.lastname: Gamble
authors.affiliation: Great Western Hospital, Swindon, United Kingdom.
authors.forename: Paul W X
authors.initials: PW
authors.lastname: Foley
authors.affiliation: Imaging Sciences & Biomedical Engineering, King's College London, London, United Kingdom; Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom.
authors.forename: Julian
authors.initials: J
authors.lastname: Bostock
authors.affiliation: Imaging Sciences & Biomedical Engineering, King's College London, London, United Kingdom; Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom.
authors.forename: Simon
authors.initials: S
authors.lastname: Claridge
authors.affiliation: Imaging Sciences & Biomedical Engineering, King's College London, London, United Kingdom; Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom.
authors.forename: Tom
authors.initials: T
authors.lastname: Jackson
authors.affiliation: Imaging Sciences & Biomedical Engineering, King's College London, London, United Kingdom; Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom.
authors.forename: Manav
authors.initials: M
authors.lastname: Sohal
authors.affiliation: Imaging Sciences & Biomedical Engineering, King's College London, London, United Kingdom; Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom.
authors.forename: Antonios P
authors.initials: AP
authors.lastname: Antoniadis
authors.affiliation: Imaging Sciences & Biomedical Engineering, King's College London, London, United Kingdom.
authors.forename: Reza
authors.initials: R
authors.lastname: Razavi
authors.affiliation: Oxford Heart Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom.
authors.forename: Tim R
authors.initials: TR
authors.lastname: Betts
authors.affiliation: Oxford Heart Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom.
authors.forename: Neil
authors.initials: N
authors.lastname: Herring
authors.affiliation: Imaging Sciences & Biomedical Engineering, King's College London, London, United Kingdom; Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom.
authors.forename: Christopher Aldo
authors.initials: CA
authors.lastname: Rinaldi
mesh_terms: D054058:Acute Coronary Syndrome / Q000191:economics / Q000401:mortality / Q000628:therapy; D000368:Aged; D001145:Arrhythmias, Cardiac / Q000191:economics / Q000401:mortality / Q000628:therapy; D002304:Cardiac Pacing, Artificial / Q000191:economics / Q000401:mortality; D058406:Cardiac Resynchronization Therapy / Q000191:economics / Q000401:mortality; D058409:Cardiac Resynchronization Therapy Devices / Q000191:economics*; D003362:Cost-Benefit Analysis; D017147:Defibrillators, Implantable / Q000191:economics*; D005260:Female; D006333:Heart Failure / Q000191:economics / Q000401:mortality / Q000628:therapy; D006760:Hospitalization / Q000191:economics; D006801:Humans; D008297:Male; D011474:Prosthesis Design; D019057:Quality-Adjusted Life Years; D012042:Registries; D006113:United Kingdom / Q000453:epidemiology
keywords: ACS, acute coronary syndrome; CRT, cardiac resynchronization therapy; CRTD, cardiac resynchronization defibrillator therapy device; HF, heart failure; ICER, incremental cost-effectiveness ratio; LV, left ventricular; NHS, National Health Service; NICE, National Institute for Health and Care Excellence; PNS, phrenic nerve stimulation; QALY, quality-adjusted life-year; cardiac resynchronization therapy; cost-effectiveness; implantable cardiac defibrillator; left ventricular pacing; quadripolar lead