Long-term cost-effectiveness of alternative management strategies for patients with life-threatening ventricular arrhythmias. Electrophysiologic Study versus Electrocardiographic Monitoring (ESVEM) Investigators

Is ambulatory monitoring for "community-acquired" syncope economically attractive? A cost-effectiveness analysis of a randomized trial of external loop recorders versus Holter monitoring

BACKGROUND

Out patient ambulatory monitoring is often performed in patients with syncope that present in the primary care setting to include or exclude an arrhythmia. The cost-effectiveness of 2 monitoring strategies was assessed in a prospective randomized trial.

METHODS

One hundred patients referred for ambulatory monitoring with syncope or presyncope were randomized to a 1-month external loop recorder (n = 49) or 48-hour Holter monitor (n = 51). Patients were offered crossover if there was failed activation or no symptom recurrence. The primary end point was symptom-rhythm correlation during monitoring. Direct costs were calculated based on the 2003 Ontario Health Insurance Plan fee schedule, combined with calculation of labor, materials, service, and overhead for diagnostic testing and related equipment.

RESULTS

Before enrollment, the cost of all previous health care resource use was USD 472 +/- USD 397 (range USD 21-USD 1965). In the loop recorder group, 63% of patients had symptom recurrence and successful activation, compared with 24% in the Holter group (P < .0001). The cost per Holter was USD 177.64, and per loop recorder, USD 533.56, with a similar cost per diagnosis with the 2 techniques. The incremental cost-effectiveness ratio of the loop recorder was USD 901.74 per extra successful diagnosis. A strategy of Holter followed by offered loop recorder trended toward lower cost than initial loop recorder followed by Holter (USD 481 +/- USD 267 vs USD 551 +/- USD 83, P = .08), but was associated with a lower overall diagnostic yield (49% vs 63%) and a resultant higher cost per diagnosis (USD 982 vs USD 871, P = .08). Bootstrapping suggested that 90% of incremental cost-effectiveness ratios were less than USD 1250.

CONCLUSION

Despite the increased upfront cost of external loop recorders, the marked improvement in diagnostic yield offsets the cost. External loop recorders are an economically attractive alternative. First-line use of external loop recorders in patients with "community-acquired" syncope and presyncope should be considered to optimize diagnostic yield given its value.

Federal sponsorship of cost-effectiveness and related research in health care: 1997-2001

OBJECTIVES

To describe recent federal sponsorship of cost-effectiveness and related health economics research to provide insight into the functioning of existing research support systems and assess the roles of federal health agencies.

METHODS

Using the PubMed database, we identified cost-effectiveness and related publications citing support from a US government entity and published during the period of 1997 through 2001, and audited them for information on funding sources, study type, and content focus.

RESULTS

Five Department of Health and Human Services agencies and centers and the Veterans Administration are cited as funders in 74% of 520 federally supported health economics publications we identified. Three-fourths of federally supported publications address five areas of high disease burden: infections, cancer, HIV/AIDS, cardiovascular disease, and substance abuse. Other high burden diseases, including mental health, diabetes, and injuries, receive less attention. Federal support of health economics studies of health education and care delivery-intervention types underexamined in the field-is relatively strong but most often focuses on substance abuse or mental health services. Each of the top federal funders has a distinct funding pattern, but there are substantial areas of overlap within which we could not identify content domains specific to one funder or another.

CONCLUSIONS

Federal support of health economics research has paralleled growth in the field. Federal funders support projects consistent with their mission and focus on high-burden disease areas. However, overlapping funding areas, ambiguity concerning agency interests within overlapping content areas, and gaps in some disease and intervention areas suggest that the coordination of health economics research funding could be improved.

Cost-effectiveness results from the US Carvedilol Heart Failure Trials Program

OBJECTIVE

To evaluate the cost-effectiveness of carvedilol, a beta-blocker that is approved for use in the US for the treatment of heart failure, based on data from Phase III clinical trials.

METHODS

We conducted an economic evaluation alongside the US Carvedilol Heart Failure Trials Program, which consisted of four concurrent, randomized, double-blind, placebo-controlled clinical trials; the mean duration of follow-up across these four trials was 6.5 months (the program was terminated prematurely based on a finding of a 65% mortality benefit). Using data from these trials, we examined the cost-effectiveness of carvedilol in terms of the estimated cost per death averted among patients randomized to such therapy versus those receiving placebo. Attention was focused on the cost of carvediol therapy plus the cost of cardiovascular-related inpatient care. Costs of care were estimated by combining infomation on healthcare utilization from the clinical trials with secondary sources of cost data.

RESULTS

Patients randomized to receive carvedilol had lower mean +/- SD estimated costs of cardiovascular-related inpatient care over 6.5 months compared with those receiving placebo ($1912 +/- $7595 vs. $4463 +/- $20,565, respectively). As mortality alsowas lower among carvedilol patients, the estimated cost per death averted was negative. The probability that carvedilol would both increase survival and decrease costs of cardiovascular-related care over a 6.5-month period was estimated to be 0.98.

CONCLUSIONS

Data from the US Carvedilol Heart Failure Trials Program indicate that carvedilol reduces mortality in patients with heart failure; our study suggests that it also may be cost-saving over a period of approximately six months.

Incremental cost-effectiveness analysis: the optimal strategy depends on the strategy set

Evaluating the incremental cost-effectiveness of a technology is critical to understanding the impact of its adoption. The purpose of this study was to evaluate, using a particular example, how the specific alternatives selected for a cost-effectiveness analysis may influence the results of the analysis. In this example, we analyzed the incremental cost-effectiveness of estriol screening for Down syndrome. Model assumptions of expected costs and effectiveness were based on previously published work involving four clinical strategies, including a "do nothing" (no screening) strategy. When the analysis started with all four strategies, two of the strategies could not be considered cost-effective because of extended dominance. However, when we eliminated the "do nothing" from the strategy set because of its clinical irrelevance, all three remaining strategies might be considered cost-effective from a policy perspective. We concluded that the incremental cost-effectiveness of clinical strategies could be strongly affected by the starting point for the analysis.

A summary and assessment of the findings and conclusions of the ESVEM trial

The Electrophysiologic Study Versus Electrocardiographic Monitoring (ESVEM) trial was completed in 1992 and the primary results were reported in 1993. Since then, considerable discussion about this trial has taken place and new trial results have been reported. Trial analysis has yielded seven principal findings to date concerning treatment of patients with ventricular tachyarrhythmias, ie: (1) similar accuracy of electrophysiologic study (EPS), Holter monitoring (HM), and EPS combined with HM for predicting antiarrhythmic drug efficacy; (2) greater efficiency and lower cost of HM; (3) improved survival associated with predicted drug efficacy; (4) predictors of response to EPS and HM; (5) greater efficacy and lower cost of therapy with sotalol compared with drugs with class-l effects; (6) lack of a relationship between presenting and recurring arrhythmia; and (7) preponderance of nonarrhythmic deaths in trial participants. A number of additional specific findings of the trial are reviewed in this symposium. Several criticisms of the trial's enrollment, methods, and efficacy criteria are reviewed and discussed. Some criticisms are valid. Many are related to misunderstandings of ESVEM trial methodology and to bias of the individual critics. Some are simply incorrect. The importance of the ESVEM trial in the present day may be limited by the growing use of implanted devices rather than drugs for treatment of ventricular tachyarrhythmias. If clinical trials ultimately prove devices to be no more effective than drugs, the findings of the ESVEM investigators will grow in importance.

Cost and efficacy analysis in the ESVEM trial: implications for diagnosis and therapy for ventricular tachyarrhythmias

Physicians must now consider the likely cost of management decisions as well as the expected effects on patient outcome. Cost-ascertainment studies identify and contrast the cost of therapies, and cost-effectiveness analysis compares the additional cost of a therapy with its additional effect on survival and quality of life. This article reviews the principles of cost-ascertainment and cost-effectiveness analysis and then presents the cost of initial and follow-up care in Electrophysiologic Study Versus Electrocardiographic Monitoring (ESVEM) trial. Finally, the cost-effectiveness of therapy guided by electrophysiologic study or Holter monitoring and of sotalol versus other drugs is reviewed, and implications for future studies are discussed.