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EXPEDITED REVIEW

The Cost Effectiveness of Implantable Cardioverter-Defibrillators

Results From the Multicenter Automatic Defibrillator Implantation Trial (MADIT)-II

Jack Zwanziger, PhD^_*,_*, W. Jackson Hall, PhD, Andrew W. Dick, PhD^_*, Hongwei Zhao, DSc, Alvin I. Mushlin, MD, ScM^_*, Rebecca Marron Hahn, MPH^_*, Hongkun Wang, MA, Mark L. Andrews, BBS, Cathleen Mooney, MS^_*, Hongyue Wang, MA and Arthur J. Moss, MD

^_* Department of Community and Preventive Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York
Department of Biostatistics and Computational Biology, University of Rochester School of Medicine and Dentistry, Rochester, New York
Department of Cardiology Division of the Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York

Manuscript received December 4, 2005; revised manuscript received March 2, 2006, accepted March 16, 2006.

^_* Reprint requests and correspondence: Dr. Jack Zwanziger, Director, Department of Health Policy and Administration, Center for Health Sciences Research, University of Illinois at Chicago, School of Public Health, Chicago, Illinois 60612-4394 (Email: jzwanzig{at}uic.edu).

OBJECTIVES: We sought to evaluate the cost implications of the implantable cardioverter-defibrillator (ICD), using utilization, cost, and survival data from the Multicenter Automatic Defibrillator Implantation Trial (MADIT)-II.

BACKGROUND: This trial showed that prophylactic implantation of a defibrillator reduces the rate of mortality in patients who experienced a previous myocardial infarction and low left ventricular ejection fraction. Given the size of the eligible population, the cost effectiveness of the ICD has substantial implications.

METHODS: Our research comprises the cost-effectiveness component of the randomized controlled trial, MADIT-II, based on utilization, cost, and survival information from 1,095 U.S. patients who were assigned randomly to receive an ICD or conventional medical care. Utilization data were converted to costs using a variety of national and hospital-specific data. The incremental cost-effectiveness ratio (iCER) was calculated as the difference in discounted costs divided by the difference in discounted life expectancy within 3.5 years. Secondary analyses included projections of survival (using three alternative assumptions), corresponding cost assumptions, and the resulting cost-effectiveness ratios until 12 years after randomization.

RESULTS: During the 3.5-year period of the study, the average survival gain for the defibrillator arm was 0.167 years (2 months), the additional costs were $39,200, and the iCER was $235,000 per year-of-life saved. In three alternative projections to 12 years, this ratio ranged from $78,600 to $114,000.

CONCLUSIONS: The estimated cost per life-year saved by the ICD in the MADIT-II study is relatively high at 3.5 years but is projected to be substantially lower over the course of longer time horizons.

Abbreviations and Acronyms   CONV = conventional therapy   HR = hazard ratio   ICD = implantable cardioverter-defibrillator   iCER = incremental cost effectiveness ratio   MADIT-II = Second Multicenter Automatic Defibrillator Implantation Trial   QALY = quality-adjusted life years   YOLS = years-of-life saved

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