Cost-effectiveness of cardiac resynchronization therapy in patients with symptomatic heart failure

BACKGROUND

Heart failure is a common, costly, and debilitating illness. Resynchronization of ventricular contraction in patients with heart failure improves ejection fraction. The long-term morbidity and costs associated with such cardiac resynchronization therapy remain unclear.

OBJECTIVE

To assess the incremental cost-effectiveness of cardiac resynchronization therapy.

DESIGN

Markov model with Monte Carlo simulation. Future costs and effects were discounted at 3%.

DATA SOURCES

Effects data were obtained from a concurrent systematic review. Health-related quality-of-life and cost data were obtained from publicly available data or from surveys.

TARGET POPULATION

Patients with reduced ventricular function and prolonged QRS.

TIME HORIZON

Lifetime.

PERSPECTIVE

U.S. health care system.

INTERVENTIONS

Cardiac resynchronization therapy versus medical therapy.

OUTCOME MEASURES

Quality-adjusted life-years (QALYs), costs, and incremental cost-effectiveness.

RESULTS OF BASE-CASE ANALYSIS

Medical therapy yielded a median of 2.64 (interquartile range, 2.47 to 2.82) discounted QALYs and a median discounted lifetime cost of 34,400 dollars (interquartile range, 31,100 dollars to 37,700 dollars). Cardiac resynchronization therapy was associated with a median incremental cost of 107,800 dollars(interquartile range, 79,800 dollars to 156,500 dollars) per additional QALY.

RESULTS OF SENSITIVITY ANALYSIS

Results were sensitive to changes in several variables, including the relative risk for death or hospitalization.

LIMITATIONS

These results apply to patients who meet the inclusion criteria of the currently completed trials.

CONCLUSIONS

The incremental cost per QALY for cardiac resynchronization is similar to that of other commonly used interventions but is sensitive to changes in several key variables. Resynchronization therapy should not be considered in patients with comorbid illness that shortens life expectancy.

Impact of informed consent requirements on cardiac arrest research in the United States: exception from consent or from research?

INTRODUCTION

Research in patients with life-threatening illness such as cardiac arrest is challenging since they can not consent. The Food and Drug Administration addressed research under emergency conditions by publishing new criteria for exception from informed consent in 1996. We systematically reviewed randomized trials over a 10-year period to assess the impact of these regulations.

METHODS

Case-control study of published trials for cardiac arrest (cases) and atrial fibrillation (controls.) Studies were identified by using structured searches of MEDLINE and EMBASE from 1992 to 2002. Included were studies using random allocation in humans with cardiac arrest or atrial fibrillation prior to enrollment. Excluded were duplicate publications. Number of American trials, foreign trials and proportion of trials of American origin were compared by using regression analysis. Changes in cardiac arrest versus atrial fibrillation trials were calculated as risk differences.

RESULTS

Of 4982 identified cardiac arrest studies, 57 (1.1%) were randomized trials. The number of American cardiac arrest trials decreased by 15% (95% CI: 8, 22%) annually (P = 0.05). The proportion of cardiac arrest trials of American origin decreased by 16% (95% CI: 10, 22%) annually (P = 0.006). Of 5596 identified atrial fibrillation studies, 197 trials (3.5%) were randomized trials. The risk difference between cardiac arrest versus atrial fibrillation trials being of American origin decreased significantly (annual difference -5.8% (95% CI: -10, -0.1%), P = 0.03).

INTERPRETATION

Fewer American cardiac arrest trials were published during the last decade, when federal consent requirements changed. Regulatory requirements for clinical trials may inhibit improvements in care and threaten public health.

Cost effectiveness of defibrillation by targeted responders in public settings

BACKGROUND

Out-of-hospital cardiac arrest is frequent and has poor outcomes. Defibrillation by trained targeted nontraditional responders improves survival versus historical controls, but it is unclear whether such defibrillation is a good value for the money. Therefore, this study estimated the incremental cost effectiveness of defibrillation by targeted nontraditional responders in public settings by using decision analysis.

METHODS AND RESULTS

A Markov model evaluated the potential cost effectiveness of standard emergency medical services (EMS) versus targeted nontraditional responders. Standard EMS included first-responder defibrillation followed by advanced life support. Targeted nontraditional responders included standard EMS supplemented by defibrillation by trained lay responders. The analysis adopted a US societal perspective. Input data were derived from published or publicly available data. Future costs and effects were discounted at 3%. Monte Carlo simulation and sensitivity analyses assessed the robustness of results. Standard EMS had a median of 0.47 (interquartile range [IQR]=0.32 to 0.69) quality-adjusted life years and a median of 14 100 dollars (IQR=8600 dollars to 21 900 dollars) costs per arrest. Targeted nontraditional responders in casinos had an incremental cost of a median 56 700 dollars (IQR=44 100 dollars to 77 200 dollars) per additional quality-adjusted life year. The results were sensitive to changes in time to defibrillation, incidence of arrest, and number of devices required to implement rapid defibrillation.

CONCLUSIONS

Where cardiac arrest is frequent and response time intervals are short, rapid defibrillation by targeted nontraditional responders may be a good value for the money compared with standard EMS. The incidence of arrest should be considered when choosing locations to implement public access defibrillation.