Key result
Replacing a resynchronisation defibrillator with a second defibrillator instead of a pacemaker in low-risk patients yielded an ICER of £305,712 per QALY gained, which is not cost-effective.
Why the study?
Is it cost-effective to replace a CRT-D with a CRT-P instead of a new CRT-D in low-risk patients at the time of generator change?
Is it cost-effective to replace a CRT-D with a CRT-P instead of a new CRT-D in low-risk patients at the time of generator change?
Downgrading from a CRT-D to a CRT-P at the time of generator replacement in patients who have not received appropriate therapies is highly cost-effective and could yield significant healthcare savings.
May support downgrading to CRT-P at generator change in low-risk patients; leaves open prospective confirmation of savings.
OBJECTIVE: Responders to cardiac resynchronisation therapy whose device has a defibrillator component and who do not receive a therapy in the lifetime of the first generator have a very low incidence of appropriate therapy after box change. We investigated the cost implications of using a risk stratification tool at the time of generator change resulting in these patients being reimplanted with a resynchronisation pacemaker. METHODS: A decision tree was created using previously published data which had demonstrated an annualised appropriate defibrillator therapy risk of 2.33%. Costs were calculated at National Health Service (NHS) national tariff rates (2016-2017). EQ-5D utility values were applied to device reimplantations, admissions and mortality data, which were then used to estimate quality-adjusted life-years (QALYs) over 5 years. RESULTS: At 5 years, the incremental cost of replacing a resynchronisation defibrillator device with a second resynchronisation defibrillator versus resynchronisation pacemaker was £5045 per patient. Incremental QALY gained was 0.0165 (defibrillator vs pacemaker), resulting in an incremental cost-effectiveness ratio (ICER) of £305 712 per QALYs gained. Probabilistic sensitivity analysis resulted in an ICER of £313 612 (defibrillator vs pacemaker). For reimplantation of all patients with a defibrillator rather than a pacemaker to yield an ICER of less than £30 000 per QALY gained (current NHS cut-off for approval of treatment), the annual arrhythmic event rate would need to be 9.3%. The budget impact of selective replacement was a saving of £2 133 985 per year. CONCLUSIONS: Implanting low-risk patients with a resynchronisation defibrillator with the same device at the time of generator change is not cost-effective by current NHS criteria. Further research is required to understand the impact of these findings on individual patients at the time of generator change.
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Claridge et al. (2017) studied Responders to cardiac resynchronisation therapy defibrillators without therapy in first generator lifetime. Replacement with a second resynchronisation defibrillator vs. Replacement with a resynchronisation pacemaker was evaluated on Incremental cost-effectiveness ratio (ICER) per QALY gained (ICER £305,712). Replacing a resynchronisation defibrillator with a second defibrillator instead of a pacemaker in low-risk patients yielded an ICER of £305,712 per QALY gained, which is not cost-effective.
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