Economic assessment of cardiac resynchronization therapy

A long-term cost-effectiveness analysis of cardiac resynchronisation therapy with or without defibrillator based on health claims data

BACKGROUND

In Germany, CRT devices with defibrillator capability (CRT-D) have become the predominant treatment strategy for patients with heart failure and cardiac dyssynchrony. However, according to current guidelines, most patients would also be eligible for the less expensive CRT pacemaker (CRT-P). We conducted a cost-effectiveness analysis for CRT-P devices compared to CRT-D devices from a German payer's perspective.

METHODS

Longitudinal health claims data from 3569 patients with de novo CRT implantation from 2014 to 2019 were used to parametrise a cohort Markov model. Model outcomes were costs and effectiveness measured in terms of life years. Transition probabilities were derived from multivariable parametric survival regression that controlled for baseline differences of CRT-D and CRT-P patients. Deterministic and probabilistic sensitivity analyses were conducted.

RESULTS

The Markov model predicted a median survival of 84 months for CRT-P patients and 92 months for CRT-D patients. In the base case, CRT-P devices incurred incremental costs of € - 13,093 per patient and 0.30 incremental life years were lost. The ICER was € 43,965 saved per life year lost. In the probabilistic sensitivity analysis, uncertainty regarding the effectiveness was observed but not regarding costs.

CONCLUSION

This modelling study illustrates the uncertainty of the higher effectiveness of CRT-D devices compared to CRT-P devices. Given the difference in incremental costs between CRT-P and CRT-D treatment, there would be significant potential cost savings to the healthcare system if CRT-D devices were restricted to patients likely to benefit from the additional defibrillator.

Device runtime and costs of cardiac resynchronization therapy pacemakers - a health claims data analysis

Introduction: This study investigates the runtime and costs of biventricular defibrillators (CRT-D) and biventricular pacemakers (CRT-P). Accurate estimates of cardiac resynchronization therapy (CRT) device runtime across all manufactures are rare, especially for CRT-P. Methods: Health claims data of a large nationwide German health insurance was used to analyze CRT device runtime. We defined device runtime as the time between the date of implantation and the date of generator change or removal. The median costs for implantation, change, and removal of a CRT device were calculated accordingly. Results: In total, the data set comprises 17,826 patients. A total of 4,296 complete runtimes for CRT-D devices and 429 complete runtimes for CRT-P devices were observed. Median device runtime was 6.04 years for CRT-D devices and 8.16 years for CRT-P devices (log-rank test p<0.0001). The median cost of implantation for a CRT-D device was 14,270 EUR, and for a CRT-P device 9,349 EUR. Conclusions: Compared to CRT-P devices, CRT-D devices had a significantly shorter device runtime of about two years. Moreover, CRT-D devices were associated with higher cost. The study provides important findings that can be utilized by cost-effectiveness analyses.

Cost-Effectiveness of Cardiac Resynchronization Therapy in Patients with Heart Failure in Thailand

Background

Cardiac resynchronization therapy (CRT) improves symptoms and survival in patients with heart failure (HF). However, the CRT devices are costly and can impose a significant burden to the relatively constrained health budgets of middle-income countries such as Thailand. The aim of this study was to analyze the cost-effectiveness of CRT in combination with optimal medical therapy (OMT) relative to patients with OMT alone.

Methods

A two-component model was used to analyze lifetime costs and quality-adjusted life-years (QALYs) from a healthcare perspective. Clinical inputs were mostly obtained from meta-analysis of landmark trials. All cost-related data, risk of non-cardiovascular death and readmission rate were based on Thai HF data. Costs and QALYs were discounted at 3%. Findings were reported as an incremental cost-effectiveness ratio (ICER). A variety of sensitivity analyses were also performed.

Results

CRT plus OMT costs more than OMT (123,279 vs 11,165 THB or 3,972.90 vs 359.81 USD), and is more effective (3.57 QALYs vs 2.49 QALYs), yielding an ICER of 104,325 THB per QALY (3,362.07 USD per QALY). CRT was cost-effective at the Thai willingness to pay threshold of 160,000 THB per QALY (5,156.30 USD per QALY). The results were sensitive to cost of CRT maintenance.

Conclusion

The use of CRT was associated with a cost-effectiveness ratio below generally accepted benchmarks for therapeutic interventions of 160,000 THB per QALY (5,156.30 USD per QALY). This suggests that the clinical benefits of CRT can be achieved at a reasonable cost in Thai HF patients.

Cost-effectiveness of heart failure therapies

Heart failure (HF) is a leading cause of morbidity and mortality worldwide. Management of HF involves accurate diagnosis and implementation of evidence-based treatment strategies. Costs related to the care of patients with HF have increased substantially over the past 2 decades, partly owing to new medications and diagnostic tests, increased rates of hospitalization, implantation of costly novel devices and, as the disease progresses, consideration for heart transplantation, mechanical circulatory support, and end-of-life care. Not surprisingly, HF places a huge burden on health-care systems, and widespread implementation of all potentially beneficial therapies for HF could prove unrealistic for many, if not all, nations. Cost-effectiveness analyses can help to quantify the relationship between clinical outcomes and the economic implications of available therapies. This Review is a critical overview of cost-effectiveness studies on key areas of HF management, involving pharmacological and nonpharmacological clinical therapies, including device-based and surgical therapeutic strategies.