Graham Nichol, MPH, MD; Padma Kaul, PhD; Ella Huszti, MSc; John F.P. Bridges, PhD
Disclaimer: The authors of this manuscript are responsible for its contents, including any clinical or treatment recommendations. No statement in this article should be construed as an endorsement by or an official position of the Agency for Healthcare Research and Quality, the U.S. Department of Health and Human Services, or the Heart and Stroke Foundation.
Acknowledgments: The authors thank Drs. David Atkins and Donald E. Casey Jr., who reviewed a draft of this work for the Agency for Healthcare Research and Quality, for their advice.
Grant Support: This research was conducted by the University of Alberta Evidence-based Practice Center under contract to the Agency for Healthcare Research and Quality (contract no. 290-02-0023). Additional support was provided by the Heart and Stroke Foundation of Canada (grant no. NA4443).
Potential Financial Conflicts of Interest:Grants received: G. Nichol (Medtronic of Canada, Medtronic, Inc., Guidant Corp., Canadian Institutes of Health Research).
Requests for Single Reprints: Graham Nichol, MD, University of Washington–Harborview Prehospital Emergency Care Research and Training Center, Harborview Medical Center, 325 Ninth Avenue, Box 359747, Seattle, WA 98104; e-mail, firstname.lastname@example.org.
Current Author Addresses: Dr. Nichol: University of Washington–Harborview Prehospital Research and Training Center, Harborview Medical Center, 325 Ninth Avenue, Box 359747, Seattle, WA 98104.
Dr. Kaul: Department of Medicine, University of Alberta, 7221 Aberhart Center—I, 8440 112 Street, Edmonton, Alberta T6G 2B7, Canada.
Ms. Huszti: Ottawa Health Research Institute, 1053 Carling Avenue, Ottawa, Ontario K1Y 4E9, Canada.
Dr. Bridges: Department of Epidemiology and Biostatistics, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH 44106-4945.
Author Contributions: Conception and design: G. Nichol.
Analysis and interpretation of the data: G. Nichol, E. Huszti, J.F.P. Bridges.
Drafting of the article: G. Nichol, J.F.P. Bridges.
Critical revision of the article for important intellectual content: E. Huszti.
Final approval of the article: G. Nichol, P. Kaul, E. Huszti.
Provision of study materials or patients: G. Nichol.
Statistical expertise: E. Huszti, J.F.P. Bridges.
Obtaining of funding: G. Nichol.
Administrative, technical, or logistic support: G. Nichol.
Collection and assembly of data: G. Nichol, P. Kaul, J.F.P. Bridges.
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.
To assess the incremental cost-effectiveness of cardiac resynchronization therapy.
Markov model with Monte Carlo simulation. Future costs and effects were discounted at 3%.
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.
Patients with reduced ventricular function and prolonged QRS.
U.S. health care system.
Cardiac resynchronization therapy versus medical therapy.
Quality-adjusted life-years (QALYs), costs, and incremental cost-effectiveness.
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 (interquartile range, $31 100 to $37 700). Cardiac resynchronization therapy was associated with a median incremental cost of $107 800 (interquartile range, $79 800 to $156 500) per additional QALY.
Results were sensitive to changes in several variables, including the relative risk for death or hospitalization.
These results apply to patients who meet the inclusion criteria of the currently completed trials.
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.
Using biventricular pacemakers to resynchronize ventricular contraction improves outcomes of heart failure in some patients. The cost-effectiveness of cardiac resynchronization is unknown.
This Markov model estimates that, compared with medical therapy, cardiac resynchronization cost about $107 800 per quality-adjusted life-year saved.
While the cost-effectiveness of cardiac resynchronization is in the general range of other commonly used interventions, the estimates depended strongly on the authors' assumptions about mortality and hospitalization rates after cardiac resynchronization.
Markov model of medical therapy for heart failure.
Markov model of cardiac resynchronization therapy (CRT) for heart failure.
Table 1. Input Data
Table 2. Potential Cost-Effectiveness of Cardiac Resynchronization Therapy Compared with Medical Therapy
Distribution of incremental costs versus incremental effects for cardiac resynchronization therapy versus medical therapy.white XQALY
Cost-effectiveness acceptability curve.
Appendix Table. Characteristics of Respondents
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Graham Nichol, Padma Kaul, Ella Huszti, John F.P. Bridges. Cost-Effectiveness of Cardiac Resynchronization Therapy in Patients with Symptomatic Heart Failure. Ann Intern Med. 2004;141:343–351. doi: 10.7326/0003-4819-141-5-200409070-00102
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Published: Ann Intern Med. 2004;141(5):343-351.
Cardiology, Heart Failure, Rhythm Disorders and Devices.
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