Background:Cardiac resynchronization therapy (CRT) reduces mortality and heart failure hospitalizations in patients with mild heart failure. Objective:To estimate the cost-effectiveness of adding CRT to an implantable cardioverter-defibrillator (CRT-D) compared with implantable cardioverter-defibrillator (ICD) alone among patients with left ventricular systolic dysfunction, prolonged intraventricular conduction, and mild heart failure. Design:Markov decision model. Data Sources:Clinical trials, clinical registries, claims data from Centers for Medicare & Medicaid Services, Centers for Disease Control and Prevention life tables. Target Population:Patients age 65 years or older with a left ventricular ejection fraction (LVEF) of 30% or less, QRS duration of 120 milliseconds or more, and New York Heart Association (NYHA) class I or II symptoms. Time Horizon:Lifetime. Perspective:Societal. Intervention:CRT-D or ICD alone. Outcome Measures:Life-years, quality-adjusted life-years (QALYs), costs, and incremental cost-effectiveness ratios (ICERs). Results of Base-Case Analysis:Use of CRT-D increased life expectancy (9.8 years versus 8.8 years), QALYs (8.6 years versus 7.6 years), and costs ($286 500 versus $228 600), yielding a cost per QALY gained of $61 700. Results of Sensitivity Analyses:The cost-effectiveness of CRT-D was most dependent on the degree of mortality reduction: When the risk ratio for death was 0.95, the ICER increased to $119 600 per QALY. More expensive CRT-D devices, shorter CRT-D battery life, and older age also made the cost-effectiveness of CRT-D less favorable. Limitations:The estimated mortality reduction for CRT-D was largely based on a single trial. Data on patients with NYHA class I were limited. The cost-effectiveness of CRT-D in patients with NYHA class I symptoms remains uncertain. Conclusion:In patients with an LVEF of 30% or less, QRS duration of 120 milliseconds or more, and NYHA class II symptoms, CRT-D appears to be economically attractive relative to ICD alone when a reduction in mortality is expected. Primary Funding Source:National Institutes of Health, University of Copenhagen, U.S. Department of Veterans Affairs.
Ann Intern Med. Published online 25 August 2015 doi:10.7326/M14-1804