Cost Advantage of Dual-Chamber Versus Single-Chamber Cardioverter-Defibrillator Implantation
Zachary Goldberger, MD*,
Brian Elbel, MPH ,
Craig A. McPherson, MD, FACC*,
A. David Paltiel, PhD and
Rachel Lampert, MD, FACC*,*
* School of Medicine, Yale University, New Haven, Connecticut
School of Epidemiology and Public Health, Yale University, New Haven, Connecticut
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Figure 1 Decision tree. The square node on the left represents a choice among the three strategies under examination. The circles represent chance nodes at each of the associated downstream probabilities for points of uncertainty. The costs listed are the non-cumulative costs associated with that particular point in the decision analytic model. AV-ICD = atrioventricular (dual-chamber) implantable cardioverter-defibrillator; EP = electrophysiologic.
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Figure 2 Extrapolation of upgrade rate for patients not undergoing electrophysiologic study (EPS). *Expected upgrade rate, determined on the basis of positive predictive value of the EPS (see Methods for details). AV-ICD = atrioventricular (dual-chamber) implantable cardioverter-defibrillator.
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Figure 3 Initial devices received June 1997 and July 2001 and indications. Offset represents upgrades received and indications. Values represent numbers of patients. CHF = congestive heart failure; HV = His ventricular interval; other abbreviations as in Figure 2.
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Figure 4 Expected per-person costs of each strategy, initial single-chamber implantation with upgrade as needed, universal dual-chamber implantation (AV-ICD), and use of electrophysiologic study to guide decision (EP-guided).
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Figure 5 Sensitivity analysis, upgrade rate. Input varied from 5% to 35%, baseline assumption 20%. Arrow denotes threshold of indifference. AV-ICD = atrioventricular (dual-chamber) implantable cardioverter-defibrillator.
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Figure 6 Sensitivity analysis, cost-differential, assuming 5% upgrade rate. Input varied from $500 to $3,000, current cost-differential $32,940. Arrow denotes threshold of indifference. AV-ICD = atrioventricular (dual-chamber) implantable cardioverter-defibrillator.
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Figure 7 Sensitivity analysis, non-device costs. Input for each cost varied from 50% to 200% of baseline values. The x-axis represents the cost-advantage of the atrioventricular (dual-chamber) implantable cardioverter-defibrillator (AV-ICD) strategy over the single-chamber strategy. The vertical line represents the $3,000 cost advantage of the AV-ICD strategy assuming baseline values. At no variation of input values does the AV-ICD strategy become more expensive (cross zero).
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