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Preventing Sudden Cardiac Death: Can We Afford the Benefit?

Stephen G. Pauker, MD; N. A. Mark Estes, MD; and Deeb N. Salem, MD
[+] Article, Author, and Disclosure Information

From Tufts-New England Medical Center and Tufts University School of Medicine; Boston, MA 02111.

Potential Financial Conflicts of Interest: Dr. Estes was the principal investigator of MADIT-II at the Tufts-New England Medical Center and is on the MADIT-CRT [Cardiac Resynchronization Therapy] Executive Committee. Both trials are ICD trials funded by Guidant Corporation.

Requests for Single Reprints: Stephen G. Pauker, MD, Tufts-New England Medical Center, Box 302, 750 Washington Street, Boston, MA 02111; e-mail, spauker@tufts-nemc.org.

Current Author Addresses: Drs. Pauker, Estes, and Salem: Tufts-New England Medical Center, Box 302, 750 Washington Street, Boston, MA 02111.

Ann Intern Med. 2005;142(8):664-666. doi:10.7326/0003-4819-142-8-200504190-00015
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Over the past 2 decades, we have made progress toward the Holy Grail of preventing sudden cardiac death. The implantable cardioverter defibrillator (ICD) is an effective but expensive therapy for primary and secondary prevention of this disorder (12). Because health care resources are limited, when therapies are both effective and expensive, one must consider whether the benefits are worth the expense. A cost-effectiveness analysis answers that question by calculating the ratio of incremental cost to incremental effectiveness. Comparisons to other therapies are then possible. The lower the incremental cost-effectiveness ratio, the better the use of resources and the more cost-effective the therapy.

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Can we afford SCD-HeFT ?
Posted on April 27, 2005
Michael Achtelik
No Affiliation
Conflict of Interest: None Declared

The authors of the editorial mentioned a number of 500.000 annual implants (McClellan and Tunis. Medicare coverage of ICDs. N Engl. J Medicine 2005; 352: 222-4) on a basis of SCD-HeFT. Still, this figure is referring to the prevalence pool of patients that would fullfill the SCd- HeFT criteria, not the annual incidence. In that respect, and considering the mean life expectation of about 9 years for SCD-HeFT patients, the number of annual implants would not be 500.000 but 56.000. The total cost would be reduced accordingly: from 15 billion$ down to 1,7 billion $ per year. The error is profound. We should refrain from "drowning" life-safing therapies in non-accurate cost numbers. Best regards, Michael Achtelik, MD

Conflict of Interest:

Manager for Market Develoment Germany

Response: Can we afford the benefit of ICDs?
Posted on June 6, 2005
Stephen G Pauker
Tufts-New Engalnd Medical Center
Conflict of Interest: None Declared

As Dr. Achtelik points out the 500,000 estimate in McClellan and Tunis's editorial referred to the total number of Medicare beneficiaries who would become eligible under expanded criteria. Assuming a life expectancy of 9 years, he estimated that the annual incidence of newly eligible patients would be one ninth of 500,000 or 56,000. Because the Medicare population is older than the MADIT-II population, the assumed life expectancy of 9 years might be rather generous. If the actual life expectancy were only 5 years, then the corresponding annual incidence would be 100,000, just among Medicare beneficiaries.

In the first several years of expanded eligibility, many of the prevalent cases might opt for an ICD. The economic burden of such a bolus would still be very large. If half of eligible patients opted for an ICD in each of the first two years, in addition to 56,000-100,000 incident cases, the cost in each of the first two years could approach $11-12 billion, an enormous burden for our medical economy. Once the initial bolus was past, the annual cost would be a mere $1.7-3.5 billion a year, a burden still big enough to require some reasonable selectivity.

Patients enrolled in the MADIT-II trial had a mean age of 65 years; so only half of them would likely be included in the estimate. Likely an equal or greater number of patients under age 65 will seek, and perhaps expect their insurers (or in reality society) to provide, an ICD. Enrollees in the SCDHeFT trial had a mean age of 60 years, suggesting that an even higher the proportion would fall beyond the Medicare estimate.

We believe that Dr. Achtelik's estimates of an annual burden of "only" $1.7 billion may be overly conservative. The issue remains controversial (1, 2). Even in the United States or Germany, resources available for medical care are limited and perhaps are becoming more so. Unrestrained use of expensive technologies may also displace other uses for our health care dollar. Many "low tech" interventions can save life years at far more modest costs. Facing such tradeoffs, we believe that insurers and societies will need to turn increasingly to formal cost- effectiveness analyses to decide not only whether we can afford the benefits but also which technologies should be applied in which populations.

Stephen G. Pauker MD N.A. Mark Estes, MD Deeb N. Salem, MD

Tufts-New England Medical Center Boston, MA


1. Buxton AE: Not everyone with an ejection fraction <_30 should="should" receive="receive" an="an" implantable="implantable" cardioverter-defibrillation="cardioverter-defibrillation" circulation="circulation" xmlns:_2005111="urn:x-prefix:_2005111" _2005111:_2537-2542.="_2005111:_2537-2542." p="p" /> 2. Moss AJ: Everyone with ejection fraction less than or equal to 30% should receive an implantable cardioverter-defibrillation; Circulation 2005;111:2542-2548.

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None declared

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