1
|
Paton MF, Gierula J, Jamil HA, Lowry JE, Byrom R, Gillott RG, Chumun H, Cubbon RM, Cairns DA, Stocken DD, Kearney MT, Witte KK. Optimising pacemaker therapy and medical therapy in pacemaker patients for heart failure: protocol for the OPT-PACE randomised controlled trial. BMJ Open 2019; 9:e028613. [PMID: 31320354 PMCID: PMC6661620 DOI: 10.1136/bmjopen-2018-028613] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Permanent artificial pacemaker implantation is a safe and effective treatment for bradycardia and is associated with extended longevity and improved quality of life. However, the most common long-term complication of standard pacemaker therapy is pacemaker-associated heart failure. Pacemaker follow-up is potentially an opportunity to screen for heart failure to assess and optimise patient devices and medical therapy. METHODS AND ANALYSIS The study is a multicentre, phase-3 randomised trial. The 1200 participants will be people who have a permanent pacemaker for bradycardia for at least 12 months, randomly assigned to undergo a transthoracic echocardiogram with their pacemaker check, thereby tailoring their management directed by left ventricular function or the pacemaker check alone, continuing with routine follow-up. The primary outcome measure is time to all-cause mortality or heart failure hospitalisation. Secondary outcomes include external validation of our risk stratification model to predict onset of heart failure and quality of life assessment. ETHICS AND DISSEMINATION The trial design and protocol have received national ethical approval (12/YH/0487). The results of this randomised trial will be published in international peer-reviewed journals, communicated to healthcare professionals and patient involvement groups and highlighted using social media campaigns. TRIAL REGISTRATION NUMBER NCT01819662.
Collapse
Affiliation(s)
- Maria F Paton
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - John Gierula
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Haqeel A Jamil
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Judith E Lowry
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Rowena Byrom
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Richard G Gillott
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Hemant Chumun
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Richard M Cubbon
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - David A Cairns
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Deborah D Stocken
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Mark T Kearney
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Klaus K Witte
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| |
Collapse
|
2
|
de Sousa J, Marques P, Martins V, Hipólito-Reis A, Duarte L, Joaquim I, Monteiro D, Boriani G, Wolff C, Grammatico A, Padeletti L. Health care cost analysis of enhanced pacing modalities in bradycardia patients: Portuguese case study on the results of the MINERVA trial. Rev Port Cardiol 2018; 37:973-978. [PMID: 30528686 DOI: 10.1016/j.repc.2018.01.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Revised: 01/04/2018] [Accepted: 01/10/2018] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION The MINERVA trial established that atrial preventive pacing and atrial antitachycardia pacing (DDDRP) in combination with managed ventricular pacing (MVP) reduces progression to permanent atrial fibrillation (AF) in patients with paroxysmal or persistent AF and bradycardia who need cardiac pacing, compared to standard dual-chamber pacing (DDDR). It was shown that AF-related health care utilization was significantly lower in the DDDRP + MVP group than in the control group. Cost analysis demonstrated significant savings related to this new algorithm, based on health care costs from the USA, Italy, Spain and the UK. OBJECTIVE To calculate the savings associated with reduced health care utilization due to enhanced pacing modalities in the Portuguese setting. METHODS The impact on costs was estimated based on tariffs for AF-related hospitalizations and costs for emergency department and outpatient visits in Portugal. RESULTS The MINERVA trial showed a 42% reduction in AF-related health care utilization thanks to the new algorithm. In Portugal, this represents a potential cost saving of 2323 euros per 100 patients in the first year and 17118 euros over a 10-year period. Considering the number of patients who could benefit from this new algorithm, Portugal could save a total of 75369 euros per year and 555410 euros over 10 years. Additional savings could accrue if heart failure and stroke hospitalizations were considered. CONCLUSION The combination of atrial preventive pacing, atrial antitachycardia pacing and an algorithm to minimize the detrimental effect of right ventricular pacing reduces recurrent and permanent AF. The new DDDRP + MVP pacing mode could contribute to significant costs savings in the Portuguese health care setting.
Collapse
Affiliation(s)
| | | | | | | | - Luís Duarte
- Unidade Local de Saúde do Baixo Alentejo, Beja, Portugal
| | | | | | - Giuseppe Boriani
- University of Bologna, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | | | | | | |
Collapse
|
3
|
Eagle KA, Crawford TC, Baman T. Project My Heart Your Heart: An Idea Whose Time Has Come. Trans Am Clin Climatol Assoc 2015; 126:158-166. [PMID: 26330671 PMCID: PMC4530717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
It is estimated that nearly 1 million patients in low-income countries die every year from bradyarrhythmias coupled with no access to a pacemaker. At the same time, it is estimated that tens of thousands of used devices could be harvested from hospitals, funeral homes, and crematories in wealthy nations if such a practice was legal and proven to be safe and efficacious. Project My Heart Your Heart is a collaborative, multinational effort with a goal of making pacemaker recycling a reality. Since its inception 4 years ago, the project has studied beliefs and attitudes of this idea among patients, pacemaker recipients, funeral home directors, and arrhythmia specialists. The project has explored the safety and efficacy of this practice in several small pilot studies. Nearly 15,000 used devices have been received and evaluated. Efforts to fully define optimal methods for sterilization and device processing have progressed positively. Safe, effective pacemaker recycling is possible and is generally supported by the public, patients, and cardiovascular specialists. An ongoing dialogue with the FDA will hopefully lead to a large pivotal study in five countries which will definitively establish this practice including optimal strategies for device removal, interrogation, sterilization, handling, implantation, and follow-up at charitable pacemaker facilities servicing low income patients throughout the world.
Collapse
Affiliation(s)
- Kim A. Eagle
- Correspondence and reprint requests: Kim. A. Eagle, MD,
Division of Cardiovascular Medicine, Department of Internal Medicine and the Samuel and Jean Frankel Cardiovascular Center, University of Michigan Health System, 1500 East Medical Center Drive, SPC 5853, Ann Arbor, MI 481105-5853
| | | | | |
Collapse
|
4
|
Affiliation(s)
- Marwan Refaat
- Division of Cardiology, University of California San Francisco Medical Center, San Francisco, California, USA
| | | |
Collapse
|
5
|
Berisso MZ, Canonero D, Caruso D, Setti S, Domenicucci S. [Cardiac resynchronization therapy with defibrillation capability: considerations on a not yet proven therapeutic superiority]. G Ital Cardiol (Rome) 2010; 11:295-305. [PMID: 20677575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Cardiac resynchronization therapy (CRT) has proven a very useful tool to treat heart failure (HF). In HF patients with severely depressed left ventricular dysfunction and ventricular dyssynchrony who remain symptomatic despite optimal medical therapy, the "reverse remodeling" induced by CRT leads to a significant improvement of survival and quality of life. The addition of the cardioversion-defibrillation function to CRT (CRT-D) is considered a further beneficial effect to reduce overall mortality secondary to a decrease in sudden death rate. Unfortunately, the amount of this additional benefit is still uncertain; in particular, how much the cardioversion-defibrillation function contributes to prolong patient survival remains to be elucidated. Such uncertainty leads to a different therapeutic approach to HF patients, i.e., an extended or restricted use of CRT-D devices. Even the most recent guidelines do not provide a clear answer to this question. The present review summarizes the current evidence regarding efficacy, effectiveness, safety, and cost-effectiveness of CRT and CRT-D, and suggests some practical solutions to the appropriate use of CRT-D on the basis of clinical, ethical and socio-economic considerations.
Collapse
|
6
|
Botto GL, Luzi M, Russo G, Mariconti B. [Cardiac resynchronization therapy with or without defibrillation backup: everything has been written?]. G Ital Cardiol (Rome) 2010; 11:306-309. [PMID: 20677576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
|
7
|
Merkely B, Roka A, Kutyifa V, Boersma L, Leenhardt A, Lubinski A, Oto A, Proclemer A, Brugada J, Vardas PE, Wolpert C. Tracing the European course of cardiac resynchronization therapy from 2006 to 2008. Europace 2010; 12:692-701. [PMID: 20200017 DOI: 10.1093/europace/euq041] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Bela Merkely
- Heart Centre, Semmelweis University, Varosmajor utca 68, Budapest H-1122, Hungary.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
8
|
Smith W. New Zealand primary implantable cardioverter defibrillator implantation and biventricular pacing guidelines. N Z Med J 2010; 123:86-96. [PMID: 20186245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Primary implantation of an implantable Cardioverter Defibrillator (ICD) is recommended for patients with ischaemic or non-ischaemic cardiomyopathy present for at least 3 months, with ejection fraction (EF) = or <30% measured = or >3 months after optimal heart failure treatment. Patients should be on maximal heart failure treatment as tolerated for = or >3 and preferably 6 months, and in New York Heart Association (NYHA) Class II or III. They should be = or >3 months remote from any revascularisation procedure or have no clinical symptoms or findings that would make them a candidate for revascularisation. There should be no associated disease reducing survival <18 months. Biventricular pacing is recommended for patients with an EF = or <35% after = or >6 weeks of optimal heart failure treatment, whose QRS duration is >149 ms or is 120-149 ms with two additional criteria for dyssynchrony (aortic pre-ejection delay >140 ms, interventricular mechanical delay >40 ms or delayed activation of the posterolateral left ventricular wall). They should be NYHA Class III, have had no major cardiovascular event in the prior 6 weeks and be in sinus rhythm. There should be no major comorbidity reducing survival <18 months or seriously impairing quality of life.
Collapse
Affiliation(s)
- Warren Smith
- Green Lane Cardiovascular Service, Auckland City Hospital, Private Bag 92024, Auckland 1030, New Zealand.
| |
Collapse
|
9
|
[Update on current care guidelines. Current care guideline: cardiac pacemaker therapy]. Duodecim 2010; 126:391-2. [PMID: 20486489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
The article presents the Finnish national guidelines for cardiac pacemaker therapy, comprising bradycardia pacing, cardiac resynchronisation therapy and implantable cardioverter-defibrillator therapy. These guidelines describe indications, the implantation technique, effectiveness, complications and patient follow-up. Emphasised are the novel aspects of bradycardia pacing therapy and the utility of cardiac resynchronisation therapy in the treatment of severe heart failure. The utility of prophylactic implantable cardioverter-defibrillators also receives emphasis. A particular focus lies in increasing awareness of advanced device therapy and the identification of patients who would benefit, in terms of improved quality of life and prolonged survival, from treatments which are clearly also cost-effective.
Collapse
|
10
|
Mele D, Toselli T, Pratola C, Artale P, Ferrari R. [Cardiac resynchronization therapy and reduction of mortality in heart failure: a proven association]. G Ital Cardiol (Rome) 2007; 8:760-769. [PMID: 18085101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Cardiac resynchronization therapy (CRT) is currently used for treatment of refractory heart failure and is effective in reducing symptoms and increasing quality of life and exercise tolerance. Data from the literature also show that CRT may prolong event-free survival and reduce heart failure mortality. This therapy is also highly cost-effective as compared to optimized medical treatment. The reduction of the risk of death occurs in both nonischemic and ischemic heart failure, although in this latter group CRT benefit seems to be less. It is still controversial whether a back-up defibrillator should be implanted to all patients undergoing CRT. Finally, left ventricular reverse remodeling occurring after 3 to 6 months of treatment predicts long-term benefit of CRT on mortality.
Collapse
Affiliation(s)
- Donato Mele
- UO di Cardiologia, Azienda Ospedaliera Universitaria, Ferrara.
| | | | | | | | | |
Collapse
|
11
|
Schoenfeld MH. Rate-modulated pacing: Are we adept at determining what is physiologic? Heart Rhythm 2007; 4:1133-5. [PMID: 17765609 DOI: 10.1016/j.hrthm.2007.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2007] [Indexed: 11/23/2022]
|
12
|
Deutsch A, Görenek B. Utility of T-wave alternans in congestive heart failure. Anadolu Kardiyol Derg 2007; 7 Suppl 1:82-4. [PMID: 17584689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
The use of implantable cardioverter defibrillator (ICD) in heart failure patients decreases the arrhythmic mortality with the cost of increasing the number of patients to be treated, and microvolt T-wave alternans (MTWA) testing can be used as a good criteria to better select the candidate for such a therapy. This article examines generalities about the mechanism of alternans, definitions of positive, negative, and indeterminate MTWA tests, and factors that can modify these results. We review clinical studies that have found MTWA as a marker of ventricular arrhythmias in patients with heart failure, independent of etiology, ischemic or idiopathic. Microvolt T-wave alternans permits the selection of low risk patients who may not benefit of ICD implantation by standard criteria, due to high negative predictive values in most studies.
Collapse
Affiliation(s)
- Alexandru Deutsch
- Department of Cardiology, Caritas Hospital, Carol Davila University, Bucharest, Romania.
| | | |
Collapse
|
13
|
Jaswal A, Singh J, Dar MA, Kler TS. What is cardiac resynchronisation therapy and who will benefit? J Assoc Physicians India 2007; 55 Suppl:62-65. [PMID: 18368870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Cardiac Resynchronisation Therapy (CRT) has been used extensively over the last years in the therapeutic management of the patients with end stage heart failure based on the data of large randomized trials on CRT. CRT improves symptoms, exercise capacity, quality of life and echocardiographic indices of severe systolic heart failure besides reduction in heart failure related hospitalizations and improvement in survival. However, there may be some non-responders as well. There is on-going research, which will identify patients without conventional indications for CRT so as to improve the responder rate. Tissue Doppler Imaging (TDI) techniques will assume an important role in identifying patients for CRT.
Collapse
Affiliation(s)
- Aparna Jaswal
- Department of Cardiac Pacing and Electrophysiology, Escorts Heart Instt. and Research Centre, Okhla Road, New Delhi
| | | | | | | |
Collapse
|
14
|
Lau CP, Tse HF, Mond HG. The impact of reimbursement on the usage of pacemakers, implantable cardioverter defibrillators and radiofrequency ablation. J Interv Card Electrophysiol 2007; 17:177-81. [PMID: 17373583 DOI: 10.1007/s10840-006-9076-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2006] [Accepted: 12/29/2006] [Indexed: 10/23/2022]
Abstract
An international questionnaire survey was carried out in Asia Pacific, Europe, Latin America and North America to assess the impact of reimbursement on the indications, types of device prescription and waiting time for pacemakers, implantable cardioverter defibrillators (ICD) and radiofrequency ablation therapy for cardiac arrhythmias. The indications for cardiac pacing can be restricted to more symptomatic patients when funding is limited, and new therapy such as cardiac resynchronization therapy (CRT) is restricted in many regions. ICD usage may be limited to secondary prevention candidates because of reimbursement, but referral doctor's ambivalence and knowledge are also important issues independent of the types of health care system. Radiofrequency ablation is generally well accepted, but reimbursement is heterogeneous, with non-fluoroscopic mapping being reimbursed only in a limited way worldwide. Thus with the exception of a well-developed health care system, reimbursement has a major impact on the delivery of arrhythmia management devices and procedures worldwide.
Collapse
Affiliation(s)
- Chu-Pak Lau
- University of Hong Kong, Room 1927, Block K, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong, China.
| | | | | |
Collapse
|
15
|
Abstract
The field of electrical device therapy has benefited from two basically independent lines of investigation demonstrating mortal benefit from either cardiac resynchronization therapy (CRT) or implantable cardioverter-defibrillator (ICD) therapy in patients with heart failure. Current clinical evidence data is insufficient to conclude that CRT-defibrillation (CRTD) offers an advantage over CRT-pacing (CRTP) alone. The cost of adding a defibrillator to the CRTP device is substantial and will act as a barrier to wide scale penetration. Annualized sudden death rates are very low in certain primary prevention populations. Consequently, the potential for overtreatment is very large and the negative costs of ICD therapy are distributed equally among those patients who will have a life saving benefit and those who were "destined" never to require the therapy. The perception that these costs are acceptable if lives are saved is commonly cited as justification for expensive therapy on a population scale, but there is an important and practical difference between costs per unit life saved and costs among patients who really never needed the device. Until the a priori predictors of volumetric response to CRT are better understood, the use of CRTD in class IV patients should be discouraged since ICD therapy is unlikely to extend life in volumetric non-responders. Similarly, the use of CRTD in patients who are "destined" for significant volumetric response is probably unwise since their risk of sudden death is minimized due to favorable substrate modification. Clinical trials comparing conventional ICDs, CRTP and CRTD are necessary to rationalize use of expensive hardware resources among different patient populations. Additionally, the importance of patient preference regarding end of life care should receive greater emphasis. While CRTP may be considered palliative in terminal heart failure, the decision to offer CRTD must include a discussion with the patient regarding mode of death and the potential for the defibrillator to replace a sudden and peaceful death with a prolonged death from progressive pump failure.
Collapse
Affiliation(s)
- Michael E Field
- Cardiac Arrhythmia Service, Brigham and Women's Hospital, Boston, MA, 02115, USA
| | | |
Collapse
|
16
|
Abstract
BACKGROUND Congestive heart failure (CHF) has been shown to affect 5% of the Canadian adult population, and leads to 9.5 deaths per 100 cardiac-related hospitalizations in Canada. The economic outcomes from biventricular pacing for heart failure are not well understood. This study analyzes resource utilization and related costs associated with CHF for patients who receive standard implantable cardiac defibrillators (ICDs) versus those who receive ICD plus biventricular pacing or cardiac resynchronization therapy (CRT). METHODS The Canadian analysis of resynchronization therapy in heart failure (CART-HF) study included 72 patients with New York Heart Association class II-IV CHF requiring an ICD. Patients were randomized to receive either ICD + CRT treatment or ICD treatment alone. Medical resource utilization data were collected for 6 months following treatment and were applied to representative costs for the provinces of Quebec and Ontario. Resource utilization was subcategorized into pharmacological therapy, physician visits, hospitalizations, adverse events, and productivity losses. RESULTS Post-treatment, per patient costs for the CRT + ICD treatment group were less than the follow-up costs for patients receiving ICD treatment only in each province. Mean savings for patients receiving biventricular therapy were CAD 2,420 dollars in Quebec and CAD 2,085 dollars in Ontario during the 6-month follow-up. CONCLUSIONS These analyses indicate that savings in post-implant health-care utilization (hospitalizations and pharmacological therapy) can offset some of the device and procedural costs associated with CRT devices.
Collapse
|
17
|
Hebert K, McKinnie J, Horswell R, Arcement L, Stevenson L. Expansion of Heart Failure Device Therapy Into a Rural Indigent Population in Louisiana: Potential Economic and Health Policy Implications. J Card Fail 2006; 12:689-93. [PMID: 17174229 DOI: 10.1016/j.cardfail.2006.08.214] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2005] [Revised: 06/22/2006] [Accepted: 08/28/2006] [Indexed: 10/23/2022]
Abstract
BACKGROUND Research regarding the use of implantable devices in patients with congestive heart failure (CHF) has shown mortality benefits. The Center for Medicare and Medicaid Services (CMS) approved new criteria for expanding coverage for such therapies. The purpose of this study was to determine the percentages of CHF patients in a rural, indigent heart failure population that would be eligible for implantable defibrillators (ICD) and cardiac resynchronization therapy (CRT) based on the new CMS criteria. METHODS AND RESULTS The new CMS guidelines were applied to information compiled in a database for 451 CHF disease management patients, at Leonard J. Chabert Medical Center. Results show that, annually, 32% of the newly identified CHF patient population would be eligible for ICD therapy and 7.3% would be eligible for CRT therapy. CONCLUSIONS Providers of health care to the indigent may lack sufficient resources for the devices and the infrastructure for device implantation and follow-up.
Collapse
Affiliation(s)
- Kathy Hebert
- Leonard J. Chabert Medical Center, Houma, Louisiana 70363, USA
| | | | | | | | | |
Collapse
|
18
|
Antoñanzas Villar F, Pinillos García M. [Equity and variability in the use of medical technologies]. Rev Esp Cardiol 2006; 59:1217-20. [PMID: 17194415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
|
19
|
Fitch-Warner K, García de Yébenes MJ, Lázaro y de Mercado P, Belaza-Santurde J. [Variations among Spanish regions in the use of three cardiovascular technologies]. Rev Esp Cardiol 2006; 59:1232-43. [PMID: 17194418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
INTRODUCTION AND OBJECTIVES There is evidence that some geographic variations in the use of medical technologies are not explained by differences in disease burden. The objectives of this study were to quantify variability in the use of percutaneous coronary intervention (PCI), implantable cardioverter-defibrillators (ICDs), and cardiac resynchronization therapy (CRT) in Spanish autonomous regions and to try to explain the variability found for the first two technologies. METHODS Linear regression models were developed in which the number of procedures performed per million population (pmp) in 2003 in each autonomous region was the dependent variable. Independent variables used included indices of technology provision, regional wealth, and disease burden. RESULTS For PCI, the mean utilization rate for the whole of Spain was 1038 procedures pmp, with a high-low ratio of 1.95. Differences in gross domestic product explained 21% of the variability, but there was no relationship between the number of procedures performed and disease burden. For ICDs, the mean number of procedures performed in the whole of Spain was 46 pmp, with a high-low ratio of 3.04. As for PCI, differences in regional wealth explained 40% of the variability, with disease burden making no contribution. For CRT, the mean number of procedures performed in Spain in 2003 was 15 pmp, with a high-low ratio of 15.7. CONCLUSIONS The considerable regional variation that exists in the use of these three medical technologies is principally explained by differences in regional wealth and not in disease burden.
Collapse
|
20
|
Wasson S, Voelker DJ, Vesom P, Wilson WR, Reddy HK. Cardiac resynchronization therapy for CHF. The rewards and risks of biventricular pacing. Postgrad Med 2006; 119:25-9. [PMID: 17128642 DOI: 10.1080/00325481.2006.11446047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Patients with advanced heart failure continue to experience high morbidity and mortality despite recent progress made with the use of such drugs as beta-blockers and angiotensin-aldosterone inhibitors. Cardiac transplantation has severe limitations due to the short supply of organs and the ineligibility of most CHF patients for this therapy. Approved heart-assist devices are cumbersome and costly. Therefore, these devices are currently used mainly in tertiary care centers in a limited number of patients. CRT has been rapidly evolving as a viable and beneficial therapy that is universally applicable by percutaneous method in patients with moderate or severe heart failure. Its relative ease of use and cost-effectiveness make it an attractive option for patients with symptomatic heart failure. Therefore, more physicians are becoming aware of the low threshold for its use.
Collapse
Affiliation(s)
- Sanjeev Wasson
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH 44195, USA.
| | | | | | | | | |
Collapse
|
21
|
|
22
|
Abstract
Cardiac resynchronisation therapy (CRT) reduces symptoms and improves left ventricular function in chronic heart failure (CHF) patients with left ventricular systolic dysfunction and prolonged QRS duration. Recent studies have demonstrated a reduction in mortality associated with CRT. When combined with an implantable cardioverter defibrillator (ICD) reduction in mortality is likely to reduce further. Cardiac resynchronisation therapy is well tolerated and free from compliance issues and therefore should be considered for all suitable patients. Identifying patients who will derive maximum benefit requires further study and has health economic implications. We review here the CRT trial evidence as well as the implantation technique and complications. We also describe a case report where an intra-aortic balloon pump was used successfully as a bridge to CRT to treat a patient with end-stage heart failure.
Collapse
Affiliation(s)
- M W H Behan
- Cardiothoracic Department, St Thomas' Hospital, Guy's and St Thomas' NHS Trust, London SE1 7EH, UK
| | | |
Collapse
|
23
|
Yao G, Freemantle N, Calvert MJ, Bryan S, Daubert JC, Cleland JGF. The long-term cost-effectiveness of cardiac resynchronization therapy with or without an implantable cardioverter-defibrillator. Eur Heart J 2006; 28:42-51. [PMID: 17110403 DOI: 10.1093/eurheartj/ehl382] [Citation(s) in RCA: 125] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS Cardiac resynchronization therapy (CRT-P) is an effective treatment for patients with heart failure and cardiac dyssynchrony with moderate or severe symptoms despite pharmacological therapy. The addition of an implantable cardioverter-defibrillator (ICD) function may further reduce the risk of sudden death. We assessed the cost-effectiveness of CRT-P compared with medical therapy (MT) alone, and the cost-effectiveness of CRT-ICD + MT compared with CRT-P + MT, on incremental cost per quality adjusted life year (QALY) and life year using data from two landmark clinical trials. METHODS AND RESULTS A Markov model with Monte Carlo simulation to assess costs, life years, and QALYs associated with CRT (+/- ICD) and MT in patients with heart failure and cardiac dyssynchrony, on the basis of a UK healthcare perspective was constructed. NYHA class distribution and transitions, associated health utilities, rates and cause of hospitalization and death were estimated from individual patient data from the CArdiac REsychronization in Heart Failure (CARE-HF trial). The estimated additional benefit on survival of an ICD was based on results from COMPANION. The base case analysis used 10 000 individual life-time simulations assuming a battery life of 6 years for CRT-P and 7 years for CRT-ICD. From a life-time perspective in a 65-year-old patient, the incremental cost-effectiveness of CRT-P compared with MT is 7538 euros (95% CI 5325-11,784 euros) per QALY gained and 7011euros (95% CI 5346-10,003 euros) per life year gained. The incremental cost-effectiveness of CRT-ICD compared with CRT-P is 47,909 euros (95% CI 35,703-79,438 euros) per QALY gained, and 35,864 euros (95% CI 26,709-56,353 euros) per life year gained. CONCLUSION Long-term treatment with CRT-P appears cost-effective compared with MT alone. From a life-time perspective, assuming a reasonable life expectancy when receiving effective treatment for heart failure, CRT-ICD may also be considered cost-effective when compared with CRT-P + MT.
Collapse
Affiliation(s)
- Guiqing Yao
- Department of Primary Care and General Practice, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
| | | | | | | | | | | |
Collapse
|
24
|
Abstract
OBJECTIVE Clinical evidence supports the use of cardiac resynchronization therapy (CRT) in advanced heart failure, but its cost-effectiveness is still unclear. This analysis assessed the economic and health consequences in the UK of implanting a CRT in patients with NYHA class III-IV heart failure. METHODS A discrete event simulation of heart failure was used to compare the course over 5 years of 1000 identical pairs of patients -- one receiving both CRT and optimum pharmacologic treatment (OPT), the other OPT alone. All inputs were obtained from the data collected in the CArdiac REsynchronization in Heart Failure (CARE-HF) trial and a hospital in the UK. Direct medical costs (in 2004 pound) from the perspective of the National Health Service were considered. Both costs and benefits were discounted at 3.5%. Sensitivity analyses addressed all model inputs and multivariate analyses were performed by varying key parameters simultaneously. RESULTS The model predicted 471 deaths and 2263 hospitalizations over 5 years with OPT alone and 348 deaths and 1764 hospitalizations with CRT, equivalent to a 26% reduction in mortality and 22% in hospitalizations, at a discounted cost of pound 11,423 per patient with CRT vs. pound 4,900 with OPT alone. CRT was predicted to increase quality-adjusted survival by 0.43 QALYs per patient, resulting in an incremental cost-effectiveness ratio of pound 15,247 per QALY gained (range: pound 12,531- pound 23,184). Sensitivity analyses revealed that this outcome was most sensitive to time horizon and cost of implantation. CONCLUSION Based on these 5-year analyses, CRT is expected to yield substantial health benefits at a reasonable cost.
Collapse
|
25
|
|
26
|
|
27
|
Roig Minguell E. [Is resynchronization possible in Spain?]. Med Clin (Barc) 2006; 126:132-4. [PMID: 16472497 DOI: 10.1157/13084029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
28
|
Abstract
BACKGROUND Biventricular pacemakers have been shown to reduce mortality and hospitalizations in heart failure (HF) patients and are indicated for those with a New York Heart Association functional class of III or IV and a QRS interval of >130 ms. However, these devices currently cost in the region of dollar US 33,500 and require replacement upon battery depletion. Therefore, determination of the cost effectiveness of resynchronization therapy is important, although little data have been published to date on this topic. METHODS AND RESULTS A cost-utility analysis from the healthcare perspective was performed using HF patients who received a biventricular pacing device in the Cleveland Clinic Foundation. The comparator was a similarly profiled group of patients who did not receive the device but were treated medically. A Markov model was used to investigate the cost effectiveness at 1 and 5 years. Second-order Monte-Carlo simulation was used to determine the variability in results, using probabilistic sensitivity analysis. Medical treatment was dominated by biventricular pacemaker treatment at both 1 and 5 years of follow-up. CONCLUSION Biventricular device insertion is an economically attractive treatment option for clinically indicated HF patients.
Collapse
Affiliation(s)
- Adrienne Heerey
- Department of Medicine, National University of Ireland, Galway, Ireland.
| | | | | | | | | |
Collapse
|
29
|
Leslie SJ, Paudyal L, Grubb NR, Denvir MA. Potential costs of cardiac re-synchronisation therapy for chronic heart failure in Scotland. Scott Med J 2005; 50:179-80. [PMID: 16374987 DOI: 10.1177/003693300505000415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
|
30
|
Feldman AM, de Lissovoy G, Bristow MR, Saxon LA, De Marco T, Kass DA, Boehmer J, Singh S, Whellan DJ, Carson P, Boscoe A, Baker TM, Gunderman MR. Cost Effectiveness of Cardiac Resynchronization Therapy in the Comparison of Medical Therapy, Pacing, and Defibrillation in Heart Failure (COMPANION) Trial. J Am Coll Cardiol 2005; 46:2311-21. [PMID: 16360064 DOI: 10.1016/j.jacc.2005.08.033] [Citation(s) in RCA: 132] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2005] [Revised: 07/07/2005] [Accepted: 08/09/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVES The analysis goal was to estimate incremental cost-effectiveness ratios (ICERs) for the Comparison of Medical Therapy, Pacing, and Defibrillation in Heart Failure (COMPANION) trial patients who received cardiac resynchronization therapy (CRT) via pacemaker (CRT-P) or pacemaker-defibrillator (CRT-D) in combination with optimal pharmacological therapy (OPT) relative to patients with OPT alone. BACKGROUND In the COMPANION trial, CRT-P and CRT-D reduced the combined risk of all-cause mortality or first hospitalization among patients with advanced heart failure and intraventricular conduction delays, but the cost effectiveness of the therapy remains unknown. METHODS In this analysis, intent-to-treat trial data were modeled to estimate the cost effectiveness of CRT-D and CRT-P relative to OPT over a base-case seven-year treatment episode. Exponential survival curves were derived from trial data and adjusted by quality-of-life trial results to yield quality-adjusted life-years (QALYs). For the first two years, follow-up hospitalizations were based on trial data. The model assumed equalized hospitalization rates beyond two years. Initial implantation and follow-up hospitalization costs were estimated using Medicare data. RESULTS Over two years, follow-up hospitalization costs were reduced by 29% for CRT-D and 37% for CRT-P. Extending the cost-effectiveness analysis to a seven-year base-case time period, the ICER for CRT-P was 19,600 dollars per QALY and the ICER for CRT-D was 43,000 dollars per QALY relative to OPT. CONCLUSIONS For the COMPANION trial patients, the use of CRT-P and CRT-D was associated with a cost-effectiveness ratio below generally accepted benchmarks for therapeutic interventions of 50,000 dollars per QALY to 100,000 dollars per QALY. This suggests that the clinical benefits of CRT-P and CRT-D can be achieved at a reasonable cost.
Collapse
Affiliation(s)
- Arthur M Feldman
- Department of Medicine, Jefferson Medical College, Philadelphia, Pennsylvania 19107, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
31
|
Fattore G, Landolina M, Bontempi L, Cacciatore G, Curnis A, Gulizia M, Padeletti L, Mazzei L, Tavazzi L. [Economic impact of cardiac resynchronization therapy in patients with heart failure. Available evidence and evaluation of the CRT-Eucomed model for analysis of cost-effectiveness]. Ital Heart J Suppl 2005; 6:796-803. [PMID: 16444923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
Several clinical trials show that cardiac resynchronization therapy (CRT) in patients with moderate-severe heart failure increases survival, improves quality of life and reduces hospital admissions. The high cost of this new technology, incurred by health organizations at the moment of the implant, requires to assess whether its use is economically rational for the Italian Health Service. The paper summarizes evidences of the impact of CRT on the use of hospital resources and on quality of life, and presents a model to calculate incremental costs per quality adjusted life years (QALYs) gained in patients with moderate-severe heart failure treated with optimal medical therapy. The model is based on efficacy data drawn from clinical trials and on other information concerning the Italian context collected and validated by a team of experts from Assobiomedica and the Italian Federation of Cardiology. The model estimates that the incremental cost per QALY gained attributable to CRT is Euro 63,225 if all effects (years of life gained, increased quality of life and reduction of hospital costs) are censored at the end of the first year after the implant and Euro 21,720 if all effects are censored at the end of the third year. Cost-effectiveness of CRT is thus strongly dependent upon the duration of its effects: longer benefits of the therapy compensate initial costs and thus make the technology more cost-effective. In order to get better estimates of the economic profile of CRT it is required to collect more precise data from routine practice on survival, quality of life and hospital resources. The model presented can be easily adapted to take into account new evidence and to calculate cost per QALY gained in regional and local contexts.
Collapse
Affiliation(s)
- Giovanni Fattore
- Facoltà di Economia Aziendale, Università degli Studi Parthenope, Napoli, Istituto di Pubblica Amministrazione e Sanità, e CeRGAS, Università degli Studi Bocconi, Milano
| | | | | | | | | | | | | | | | | |
Collapse
|
32
|
Calvert MJ, Freemantle N, Yao G, Cleland JGF, Billingham L, Daubert JC, Bryan S. Cost-effectiveness of cardiac resynchronization therapy: results from the CARE-HF trial. Eur Heart J 2005; 26:2681-8. [PMID: 16284203 DOI: 10.1093/eurheartj/ehi662] [Citation(s) in RCA: 102] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
AIMS Whilst the CArdiac REsynchronization in Heart Failure (CARE-HF) trial has shown that cardiac resynchronization therapy (CRT) leads to reduced morbidity and mortality, the cost-effectiveness of this therapy remains uncertain. The aim of this study was to evaluate the incremental cost per quality adjusted life year (QALY) gained and incremental cost per life year gained of CRT plus medical therapy compared to medical therapy alone. METHODS AND RESULTS This prospective analysis based on intention to treat data from all patients enrolled in the CARE-HF trial at 82 clinical centres in 12 European countries. A total of 813 patients with New York Heart Association class III or IV heart failure due to left ventricular systolic dysfunction and cardiac dyssynchrony were randomized to CRT plus medical therapy (n = 409) vs. medical therapy alone (n = 404). During a mean follow-up of 29.4 months CRT was associated with increased costs (4316, 95% CI: 1327-7485), survival (0.10 years, 95% CI: -0.01-0.21), and QALYs (0.22, 95% CI: 0.13-0.32). The incremental cost-effectiveness ratio was 19 319 per QALY gained (95% CI: 5482-45 402) and 43 596 per life-year gained (95% CI: -146 236-223 849). These results were sensitive to the costs of the device, procedure, and hospitalization. CONCLUSION Treatment with CRT appears cost-effective at the notional willingness to pay threshold of 29 400 (20,000 pounds sterlings) per QALY gained.
Collapse
Affiliation(s)
- Melanie J Calvert
- Department of Primary Care and General Practice, University of Birmingham, Edgbaston, UK
| | | | | | | | | | | | | |
Collapse
|
33
|
Goldberger Z, Elbel B, McPherson CA, Paltiel AD, Lampert R. Cost Advantage of Dual-Chamber Versus Single-Chamber Cardioverter-Defibrillator Implantation. J Am Coll Cardiol 2005; 46:850-7. [PMID: 16139136 DOI: 10.1016/j.jacc.2005.05.061] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2004] [Revised: 04/29/2005] [Accepted: 05/17/2005] [Indexed: 11/17/2022]
Abstract
OBJECTIVES The purpose of this study was to determine the least expensive strategy for device selection in patients receiving implantable cardioverter-defibrillators (ICDs). BACKGROUND Device cost for a single-chamber ICD is less than an atrioventricular (dual-chamber) ICD (AV-ICD); however, some patients without clinical need for AV-ICD at implantation might require a later upgrade, potentially offsetting the initial cost advantage of the single-chamber device. METHODS Decision analysis was used to estimate expected resource utilization costs of three alternative implantation strategies: 1) single-chamber device in all, with later upgrade to AV-ICD if needed; 2) initial implantation of an AV-ICD in all; and 3) targeted device selection on the basis of results of electrophysiologic testing (presence or absence of induced bradyarrhythmias or atrial arrhythmias). Clinical base estimates were obtained from retrospective review of all patients receiving ICDs between June 1997 and July 2001 at a single university hospital. Economic inputs were collected from national and single-center sources. RESULTS In patients without other indications for electrophysiologic study (EPS), the expected per-person cost was least with the strategy of universal initial AV-ICD implantation (36,232 dollars) compared with initial single-chamber ICD/upgrade as needed (39,230 dollars) or EPS-guided selection (41,130 dollars). Sensitivity analyses demonstrated that universal AV-ICD implantation remained least expensive with upgrade rates as low as 10%. At a 5% upgrade rate, AV-ICD remained cheapest if the device cost-differential narrowed to 1,568 dollars. For patients undergoing EPS for risk assessment, EP-guided selection was least expensive. CONCLUSIONS The strategy of universal AV-ICD implantation, which provides the benefits of dual-chamber capability while obviating any potential need for future upgrade, is the least costly strategy for most patient populations receiving ICDs.
Collapse
|
34
|
Abstract
This article reviews controversies in cardiac pacing in four areas: methods to prevent unnecessary right ventricular pacing and optimal ventricular pacing sites in the bradycardia population, pacing for prevention of atrial fibrillation (AF), a novel pacing technique for the treatment of heart failure, and pacing for the treatment of sleep apnea. Frequent right ventricular pacing has been reported to increase the incidence of AF and congestive heart failure. However, many patients with pacemakers for bradycardia have intrinsic atrioventricular conduction most of the time. Optimal programming of pacemakers and new algorithms designed to reduce unnecessary ventricular pacing are discussed. Pacing algorithms for prevention of AF have generally been shown to be ineffective. Atrial antitachycardia pacing has been shown to reduce the burden of atrial tachyarrhythmias in selected patients. Cardiac contractility modulation has recently been reported to be a promising new approach to the treatment of heart failure. Some pacing techniques may be effective in the treatment of sleep apnea but larger, long-term clinical trials are required to demonstrate a significant clinical benefit.
Collapse
Affiliation(s)
- Anne M Gillis
- Faculty of Medicine, University of Calgary, HSC Room 1634, 3330 Hospital Drive NW, Calgary, AB T2N 4N1, Canada.
| | | |
Collapse
|
35
|
O'Brien BJ, Blackhouse G, Goeree R, Healey JS, Roberts RS, Gent M, Connolly SJ. Cost-effectiveness of physiologic pacing: Results of the Canadian Health Economic Assessment of Physiologic Pacing. Heart Rhythm 2005; 2:270-5. [PMID: 15851317 DOI: 10.1016/j.hrthm.2004.12.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2004] [Accepted: 12/14/2004] [Indexed: 11/22/2022]
Abstract
OBJECTIVES The purpose of this study was to determine the cost-effectiveness of physiologic pacemakers. BACKGROUND The Canadian Trial of Physiologic Pacing (CTOPP) was a large randomized trial that evaluated the efficacy of physiologic pacing compared with ventricular pacing. CTOPP also included a prospective cost-effectiveness substudy. METHODS Resource usage and costs were collected from a subset of 472 patients (of 1,094) who received a physiologic pacemaker and 586 (of 1,474) who received a ventricular pacemaker. Costs included initial pacemaker implantation and all health care follow-up costs over a follow-up of 5.2 years. Costs are reported in 2004 Canadian dollars (1 Canadian dollar = 0.76 US dollars), with adjustments for censoring. Incremental cost-effectiveness was estimated as the ratio of the difference (treatment-control) in mean cost to the difference in life expectancy (mean survival), with costs and effects discounted at 3% per year. RESULTS Over a mean follow-up of 3.1 years, physiologic pacing was associated with a gain of 0.01 life-years. This benefit increases to 0.25 life-years in the subgroup of patients with an intrinsic (unpaced) heart rate < or =60 bpm. Physiologic pacing was more expensive than ventricular (16,833 Canadian dollars vs 13,857 US dollars), largely because of the increased cost of dual-chamber devices. Among all substudy patients, the incremental cost-effectiveness of physiologic pacing is 297,600 Canadian dollars per life-year gained; however, this value falls to 16,343 Canadian dollars in patients with an intrinsic heart rate >60. CONCLUSIONS In the short term, a strategy of routine implantation of physiologic pacemakers is not cost-effective by currently accepted standards. The selective use of these devices in patients likely to be pacemaker dependent appears to be cost-effective. Further studies with longer follow-up and which consider the benefit of reducing nonfatal cardiac events would be valuable.
Collapse
Affiliation(s)
- Bernie J O'Brien
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | | | | | | | | | | | | |
Collapse
|
36
|
Wijetunga M, Strickberger SA. Can an expensive therapy save lives if the disease is not life threatening? Heart Rhythm 2005; 2:276. [PMID: 15851318 DOI: 10.1016/j.hrthm.2005.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
37
|
Abstract
OBJECTIVES This article describes the framework of a comprehensive European model developed to assess clinical and economic outcomes of cardiac resynchronization therapy (CRT) versus optimal pharmacological therapy (OPT) alone in patients with heart failure. METHODS The model structure is based on information obtained from the literature, expert opinion, and a European CRT Steering Committee. The decision-analysis tool allows a consideration of direct medical and indirect costs, and computes outcomes for distinctive periods of time up to 5 years. Qualitative data can also be entered for cost-utility analysis. Model input data for a preliminary economic appraisal of the economic value of CRT in Germany were obtained from clinical trials, experts, health statistics, and medical tariff lists. RESULTS The model offers comprehensive analysis capabilities and high flexibility so that it can easily be adapted to any European country or special setting. The illustrative analysis for Germany indicates that CRT is a cost-effective intervention. Although CRT is associated with average direct medical net costs of Euro 5880 per patient, this finding means that 22% of its upfront implantation cost is recouped already within 1 year because of significantly decreased hospitalizations. With 36,600 Euros the incremental cost per quality-adjusted life-year (QALY) gained is below the euro equivalent (41,300 Euros, 1 Euro = US1.21 dollars) of the commonly used threshold level of US50,000 dollars considered to represent cost-effectiveness. The sensitivity analysis showed these preliminary results to be fairly robust towards changes in key assumptions. CONCLUSIONS The European CRT model is an important tool to assess the economic value of CRT in patients with moderate to severe heart failure. In the light of the planned introduction of Diagnosis Related Group (DRG) based reimbursement in various European countries, the economic data generated by the model can play an important role in the decision-making process.
Collapse
Affiliation(s)
- Kurt Banz
- OUTCOMES INTERNATIONAL, Basel, Switzerland.
| |
Collapse
|
38
|
Leibovitch ER. Once upon a time, heart failure was easy. Geriatrics (Basel) 2005; 60:31-3. [PMID: 15742921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023] Open
|
39
|
Rinfret S, Cohen DJ, Lamas GA, Fleischmann KE, Weinstein MC, Orav J, Schron E, Lee KL, Goldman L. Cost-effectiveness of dual-chamber pacing compared with ventricular pacing for sinus node dysfunction. Circulation 2005; 111:165-72. [PMID: 15630030 DOI: 10.1161/01.cir.0000151810.69732.41] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Compared with single-chamber ventricular pacing, dual-chamber pacing can reduce adverse events and, as a result, improve quality of life in patients paced for sick sinus syndrome. It is not clear, however, how these benefits compare with the increased cost of dual-chamber pacemakers. METHODS AND RESULTS We used 4-year data from a 2010-patient, randomized trial to estimate the incremental cost-effectiveness of dual-chamber pacing compared with ventricular pacing and then projected these findings over the patients' lifetimes by using a Markov model that was calibrated to the first 5 years of in-trial data. To assess the stability of the findings, we performed 1000 bootstrap analyses and multiple sensitivity analyses. During the first 4 years of the trial, dual-chamber pacemakers increased quality-adjusted life expectancy by 0.013 year per subject at an incremental cost-effectiveness ratio of 53,000 dollars per quality-adjusted year of life gained. Over a lifetime, dual-chamber pacing was projected to increase quality-adjusted life expectancy by 0.14 year with an incremental cost-effectiveness ratio of approximately 6800 dollars per quality-adjusted year of life gained. In bootstrap analyses, dual-chamber pacing was cost-effective in 91.9% of simulations at a threshold of 50,000 dollars per quality-adjusted year of life and in 93.2% of simulations at a threshold of 100,000 dollars. Its cost-effectiveness ratio was also below this threshold in numerous sensitivity analyses that varied key estimates. CONCLUSIONS For patients with sick sinus syndrome requiring pacing, dual-chamber pacing increases quality-adjusted life expectancy at a cost that is generally considered acceptable.
Collapse
Affiliation(s)
- Stéphane Rinfret
- Department of Medicine, Centre Hospitalier de l'Université de Montréal (CHUM), University of Montreal, Montreal, Canada
| | | | | | | | | | | | | | | | | |
Collapse
|
40
|
Summaries for patients. Cost-effectiveness of rate control vs. rhythm control for patients with atrial fibrillation. Ann Intern Med 2004; 141:I20. [PMID: 15520416 DOI: 10.7326/0003-4819-141-9-200411020-00001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
|
41
|
McAlister F, Ezekowitz J, Wiebe N, Rowe B, Spooner C, Crumley E, Hartling L, Kaul P, Nichol G, Klassen T. Cardiac resynchronization therapy for congestive heart failure. Evid Rep Technol Assess (Summ) 2004:1-8. [PMID: 15612141 PMCID: PMC4781016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
|
42
|
Dixon LJ, Murtagh JG, Richardson SG, Chew EW. Reduction in hospitalization rates following cardiac resynchronisation therapy in cardiac failure: experience from a single centre. Europace 2004; 6:586-9. [PMID: 15519262 DOI: 10.1016/j.eupc.2004.08.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2004] [Accepted: 08/02/2004] [Indexed: 10/25/2022] Open
Abstract
AIMS Frequent, lengthy hospital admissions for congestive cardiac failure (CCF) result in excessive health care costs. Cardiac resynchronisation therapy (CRT) is a novel treatment option for patients with CCF and associated cardiac conduction defects. We investigated whether CRT resulted in significant improvements in New York Heart Association (NYHA) symptom class, exercise tolerance, and hospitalization rates in such patients. METHODS Twenty-seven patients who underwent CRT in a single centre were studied, with NYHA symptom class, exercise tolerance and hospitalization rates noted in the 12 months prior to and following CRT. RESULTS Following 12 months of CRT, NYHA symptom class improved from 3.3 +/- 0.5 to 2.1 +/- 0.4 (P < 0.05). Exercise tolerance, assessed by 6 min hall walk test increased by 64% from 195 +/- 114 m to 320 +/- 85 m (P = 0.007). Days in hospital for stabilisation of cardiac failure decreased by 98% from 472 to 9 days (P < 0.001). Significant hospitalization cost savings of 201,684 euros were calculated, with an overall saving of 12,420 euros. CONCLUSIONS These data demonstrate that CRT results in significant improvement in clinical parameters, and considerable reductions in hospital admissions, and costs in patients with CCF.
Collapse
Affiliation(s)
- Lana J Dixon
- Regional Cardiology Centre, Belfast City Hospital, Northern Ireland.
| | | | | | | |
Collapse
|
43
|
Summaries for patients. The cost-effectiveness of cardiac resynchronization therapy for heart failure. Ann Intern Med 2004; 141:I29. [PMID: 15353442 DOI: 10.7326/0003-4819-141-5-200409070-00104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
|
44
|
Abstract
BACKGROUND 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. OBJECTIVE To assess the incremental cost-effectiveness of cardiac resynchronization therapy. DESIGN Markov model with Monte Carlo simulation. Future costs and effects were discounted at 3%. DATA SOURCES 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. TARGET POPULATION Patients with reduced ventricular function and prolonged QRS. TIME HORIZON Lifetime. PERSPECTIVE U.S. health care system. INTERVENTIONS Cardiac resynchronization therapy versus medical therapy. OUTCOME MEASURES Quality-adjusted life-years (QALYs), costs, and incremental cost-effectiveness. RESULTS OF BASE-CASE ANALYSIS 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 dollars (interquartile range, 31,100 dollars to 37,700 dollars). Cardiac resynchronization therapy was associated with a median incremental cost of 107,800 dollars(interquartile range, 79,800 dollars to 156,500 dollars) per additional QALY. RESULTS OF SENSITIVITY ANALYSIS Results were sensitive to changes in several variables, including the relative risk for death or hospitalization. LIMITATIONS These results apply to patients who meet the inclusion criteria of the currently completed trials. CONCLUSIONS 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.
Collapse
Affiliation(s)
- Graham Nichol
- University of Washington-Harborview Prehospital Emergency Care Research and Training Center and Harborview Medical Center, Seattle, Washington 98104, USA.
| | | | | | | |
Collapse
|
45
|
|
46
|
Reddy P, Kalus JS, Caron MF, Horowitz S, Karapanos A, Coleman CI, Kluger J, White CM. Economic Analysis of Intravenous Plus Oral Amiodarone, Atrial Septal Pacing, and Both Strategies to Prevent Atrial Fibrillation After Open Heart Surgery. Pharmacotherapy 2004; 24:1013-9. [PMID: 15338850 DOI: 10.1592/phco.24.11.1013.36132] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVES To compare the cost-effectiveness of intravenous plus oral amiodarone, atrial septal pacing, and both strategies combined to prevent atrial fibrillation after open heart surgery. Secondary objectives were to compare the cost-effectiveness of amiodarone versus no amiodarone and of pacing versus no pacing, and to compare hospitalization costs of the various strategies. DESIGN Piggyback cost analysis of a randomized, 2 x 2 factorial trial. SETTING Urban academic hospital. PATIENTS One hundred and sixty patients with coronary artery and/or valvular disease. INTERVENTION Patients were randomized to receive amiodarone or matching placebo and then further randomized to receive atrial septal pacing or no pacing. MEASUREMENTS AND MAIN RESULTS The economic analysis was conducted from a hospital perspective. Charges were converted to costs using cost:charge ratios. For the cost-effectiveness analysis, a joint distribution of costs and effectiveness was performed using the nonparametric bootstrap method. Amiodarone plus pacing significantly decreased the frequency of atrial fibrillation after open heart surgery, compared with amiodarone alone, pacing alone, and placebo. Total costs (mean+/-SD) were $27,026+/-30,226 for the placebo group, $22,725+/-17,661 for the amiodarone group, $33,868+/-60,309 for the pacing group, and $18,697+/-8174 for the amiodarone plus pacing group (p=0.27). In the joint distribution cost-effectiveness analysis, when compared with placebo, the probability of lower cost but higher effect (superiority) was 67% for amiodarone, 15% for pacing, and 97% for amiodarone plus pacing. In the multivariate analysis, preoperative beta-blockers and amiodarone were negatively associated with hospital costs (p<0.05). CONCLUSIONS Data suggest that both amiodarone alone and the combination of amiodarone plus pacing are cost-effective compared with placebo. Additional comparative studies of these strategies are warranted to confirm these findings.
Collapse
|
47
|
Kiencke S, Osswald S. [Cardiac resynchronization therapy (CRT)--a new option for severe heart failure]. Ther Umsch 2004; 61:265-70. [PMID: 15139318 DOI: 10.1024/0040-5930.61.4.265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The increasing incidence of heart failure is an important issue in cardiovascular medicine. Apart from pump failure, conduction disturbances and arrhythmias may play a major role and must be considered when selecting the therapy. In addition to optimal drug therapy, cardiac resynchronization (CRT) with biventricular stimulation offers a new therapeutic option.
Collapse
Affiliation(s)
- S Kiencke
- Abteilung für Kardiologie, Universitätskliniken Basel
| | | |
Collapse
|
48
|
Special report: cost-effectiveness of implantable cardioverter-defibrillators in a MADIT-II population. Technol Eval Cent Assess Program Exec Summ 2004; 19:1-2. [PMID: 15314827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
|
49
|
Affiliation(s)
- Angelo Auricchio
- Division of Cardiology, University Hospital, Leipziger Strasse 44, 39120 Magdeburg, Germany.
| | | |
Collapse
|
50
|
Affiliation(s)
- Christophe Leclercq
- The Johns Hopkins Hospital, Cardiology Division, 600 N Wolfe St, Carnegie 568, Baltimore, MD 21287-6568, USA.
| | | |
Collapse
|