European Heart Journal Advance Access published online on November 16, 2006
European Heart Journal, doi:10.1093/eurheartj/ehl382
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The long-term cost-effectiveness of cardiac resynchronization therapy with or without an implantable cardioverter-defibrillator
1 Department of Primary Care and General Practice, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
2 Health Services Management Centre, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
3 Department of Cardiology, Hôpital Pontchaillou, Rennes, France
4 Department of Cardiology, University of Hull, Castle Hill Hospital, Kingston upon Hull, UK
Received 21 June 2006; revised 26 September 2006; accepted 26 October 2006.
* Corresponding author. Tel: +44 121 414 7943; fax: +44 121 414 3353. E-mail address: n.freemantle{at}bham.ac.uk
Aims Cardiac resynchronization therapy (CRT-P) is an effective treatment for patients with heart failure and cardiac dyssynchrony with moderate or severe symptoms despite pharmacological therapy. The addition of an implantable cardioverter-defibrillator (ICD) function may further reduce the risk of sudden death. We assessed the cost-effectiveness of CRT-P compared with medical therapy (MT) alone, and the cost-effectiveness of CRT–ICD+MT compared with CRT-P+MT, on incremental cost per quality adjusted life year (QALY) and life year using data from two landmark clinical trials.
Methods and results A Markov model with Monte Carlo simulation to assess costs, life years, and QALYs associated with CRT (± ICD) and MT in patients with heart failure and cardiac dyssynchrony, on the basis of a UK healthcare perspective was constructed. NYHA class distribution and transitions, associated health utilities, rates and cause of hospitalization and death were estimated from individual patient data from the CArdiac REsychronization in Heart Failure (CARE-HF trial). The estimated additional benefit on survival of an ICD was based on results from COMPANION. The base case analysis used 10 000 individual life-time simulations assuming a battery life of 6 years for CRT-P and 7 years for CRT–ICD. From a life-time perspective in a 65-year-old patient, the incremental cost-effectiveness of CRT-P compared with MT is 
7538 (95% CI 5325–11 784) per QALY gained and 7011 (95% CI 5346–10 003) per life year gained. The incremental cost-effectiveness of CRT–ICD compared with CRT-P is 47 909 (95% CI 35 703–79 438) per QALY gained, and 35 864 (95% CI 26 709–56 353) per life year gained.
Conclusion Long-term treatment with CRT-P appears cost-effective compared with MT alone. From a life-time perspective, assuming a reasonable life expectancy when receiving effective treatment for heart failure, CRT–ICD may also be considered cost-effective when compared with CRT-P+MT.
Key Words: Cost effectiveness • Cardiac resynchronization therapy • Implantable cardioverter defibrillator • Markov model • Individual simulation
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