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HEART RHYTHM DISORDERS

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^_*,_*

^_* Medicine
Epidemiology and Public Health, Yale University, New Haven, Connecticut

Manuscript received June 25, 2004; revised manuscript received April 29, 2005, accepted May 17, 2005.

^_* Reprint requests and correspondence: Dr. Rachel Lampert, Yale University School of Medicine, Section of Cardiology, 333 Cedar Street, FMP 3, New Haven, Connecticut 06520 (Email: rachel.lampert{at}yale.edu).

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) compared with initial single-chamber ICD/upgrade as needed ($39,230) or EPS-guided selection ($41,130). 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. 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.

Abbreviations and Acronyms   ACC = American College of Cardiology   AHA = American Heart Association   AV-ICD = atrioventricular (dual-chamber) implantable cardioverter-defibrillator   AVID = Anti-arrhythmics Versus Implantable Defibrillators trial   CHF = congestive heart failure   DAVID = Dual-Chamber and VVI Implantable Defibrillator trial   EPS = electrophysiology/electrophysiologic study   ICD = implantable cardioverter-defibrillator   MADIT = Multicenter Automatic Defibrillator Implantation Trial   MUSTT = Multicenter UnSustained Tachycardia Trial   NASPE = North American Society of Pacing and Electrophysiology   SCD-HeFT = Sudden Cardiac Death in Heart Failure Trial

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