Funding for cardiac pacing and defibrillators in Calgary: the Robin Hood philosophy

The impact of pulse generator longevity on the long-term costs of cardiac pacing

The long-term costs of cardiac pacing include the device costs, the procedural costs, the follow-up costs, and the replacement costs. At present, there is significant variability in the efficiencies of the integrated circuits and the total battery capacity among different pulse generators that will influence replacement rates over time. Accordingly, we compared the influence of pulse generator longevity on the long-term costs of pacing. The longevity of pulse generators was calculated based on the electrical characteristics of the device and the percentage of time the patient is paced. Replacement rates of pulse generators were estimated for our patient population over a 20-year period, based on patient survival and pulse generator longevity. The costs of pacing over this 20-year follow-up period were then calculated. The longevity of DDDR devices presently implanted in the United States ranges from 8-14 years, assuming that patients are paced 50% of the time. Replacement rates in this population over a 20-year follow-up period were calculated to range from 0.34-0.66, and the total costs of pacing would range from $11,898-14,900 per patient. The longevity of SSIR devices ranges from 7-20 years, assuming that patients are paced 50% of the time. Replacement rates were calculated over the 20-year follow-up period to range from 0.20-0.84, and the total costs of VVIR pacing would range from $8,331-13,286. Based on the proportion of pulse generator models implanted in patients in the United States, the maximum cost differential to the health care system is approximately $424 million/year comparing the devices with the shortest and greatest longevities. Thus, pulse generator longevity may significantly influence the long-term costs of pacing. Patient survival and pulse generator system longevity should be considered when selecting the appropriate pacing system for the individual patient.

The impact of implantable cardioverter defibrillator therapy on health care systems

Implantable cardioverter defibrillators (ICDs) are now widely used for the secondary prevention of sudden cardiac death and are being offered as a primary preventive therapy. This technology has potential for significant fiscal impact on health care budgets. Technologic innovation will result in more complex devices that are more effective and better accepted by patients and physicians. The clinical impact of these devices will be predicated, in part, by absolute survival benefits but also by their relative advantages over alternative therapies in terms of survival, safety, morbidity, quality of life, and cost. The impact on public health will depend on the effectiveness of screening methods for identification of populations likely to benefit from primary prevention. Risk stratification algorithms are now being tested in several ongoing clinical trials. Dilution of benefit by competing illnesses may occur to different extents in individual patient populations. The economic impact is predicated on the future cost of ICD systems, limitation of hospitalization costs associated with this therapy, and accurate prospective stratification in primary prevention populations. Cost efficacy analyses and quality of life assessment in ongoing and future clinical trials are essential to the development of this therapy and its diffusion into different health care systems. Achievement of clinical benefits, functional independence, and a return to gainful employment by patients will be important determinants of the support lent by health care systems to the dissemination of this therapy.