CAN IMPLANTABLE CARDIOVERTER-DEFIBRILLATOR THERAPY REDUCE HEALTH-CARECOSTS

This article presents a comparison of the costs and the cost effective ness of defibrillator implantation in a hypothetical scenario for the years 1996-2000, with recently reported actual data from the Dutch pro spective study over the years 1989-1993. Recently, technological advan ces in pulse generator and leads have revolutionized implantable cardi overter-defibrillator (ICD) therapy. Major advances include (1) transv enous single lead positioning and (2) a tremendously reduced size, com bined with prolonged longevity of the pulse generator. Both have simpl ified implantation technique and provided for superior effectiveness a nd lower costs. This suggests that a more favorable cost-effectiveness is to be expected. The study group reported here consisted of patient s successfully resuscitated after cardiac arrest due to malignant vent ricular tachyarrhythmias in the chronic stage of myocardial infarction . During a mean follow-up of 27 months, starting on the day of therape utic decision making, total costs and the cost-effectiveness ratio wer e estimated. Actual data from the prospective study in 1989-1993 are c ompared with a hypothetical scenario for 1996-2000. Mortality and cost s for hospitalization per day, per procedure, and per device are taken from the prospective study and equalized for both scenarios. Transtho racic lead positioning and abdominal implantation of a Ventak P (CPI) defibrillator with +/-3 years longevity were characteristic of the rec ently completed prospective study. The hypothetical future scenario us es the Ventak Mini-2 with assumed 5 years longevity, implanted pectora lly and connected to a single transvenous lead. Implantation will be c arried out in the catheterization laboratory and as first-choice treat ment. Due to prolonged longevity of the device and shorter hospitaliza tion, a cost reduction of US $11,530 per patient is expected. Total co sts per patient in the 1989-1993 prospective study in the (1) conventi onal arm (drugs first choice), (2) early ICD arm (ICD first choice), a nd (3) early ICD arm in the 1996-2000 study (ICD first choice) are $63 ,032, $56,067, and $44,537, respectively. The corresponding cost-effec tiveness ratios are $87, $64, and $51 per day alive, respectively. Thu s, it appears that modem ICD technology will be associated with an inc reasing reduction in healthcare costs, at least in selected patients. This reduction is associated with a more favorable cost-effectiveness ratio.