Europace Advance Access originally published online on April 9, 2009
Europace 2009 11(6):716-726; doi:10.1093/europace/eup068
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ICD
Lifetime cost-effectiveness of prophylactic implantation of a cardioverter defibrillator in patients with reduced left ventricular systolic function: results of Markov modelling in a European population
1 Clinical Cardiology, National Heart and Lung Institute, Imperial College, Dovehouse Street, London SW3 6LY, UK; 2 Faculty of Medicine, Department of Community Health Sciences, University of Calgary and Principal Consultant to i3 Innovus, Calgary, Alberta, Canada; 3 Centre for Health Economics, University of York, York, UK; 4 Health Economics and Outcomes Research, i3 Innovus, Burlington, Ontario, Canada; 5 Health Economics and Outcomes Research, i3 Innovus, Stockholm, Sweden; 6 Cliniques Universitaires UCL de Mont-Godinne, Arrhythmology Unit, Yvoir, Belgium; 7 Clinical EP Laboratory, University Hospital Gasthuisberg, University of Leuven, Leuven, Belgium; 8 Priesterse Heidestraat 75, B-3560 Lummen, Belgium; 9 Department of Cardiology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden; 10 Institute of Cardiology, University of Bologna, S. Orsola-Malpighi University Hospital, Bologna, Italy
Aims: Current European guidelines recommend prophylactic implantation of cardioverter defibrillators (ICDs) in patients with a reduced left ventricular ejection fraction (LVEF) who are not in NYHA class IV and have reasonable life expectancy. Cost and benefit implications of this recommendation have not been reported from a European perspective.
Methods and results: Markov modelling estimated lifetime costs and effects [life years (LY) and quality-adjusted LY (QALY) gained] of prophylactic ICD implantation vs. conventional treatment, among patients with a reduced LVEF. Efficacy was estimated from a meta-analysis of mortality rates in the six primary prevention trials with inclusion criteria matching ACC/AHA/ESC Class I or IIa recommendations. Direct medical costs were estimated using Belgian national references. Costs and effects were discounted at 3 and 1.5% per annum, respectively. Probabilistic sensitivity and scenario analyses estimated the uncertainty around the incremental cost-effectiveness ratio. An ICD implantation increased the lifetime direct costs by 
46 413. Estimated mean LY/QALY gained were 1.88/1.57, respectively. Probabilistic analysis estimated mean lifetime cost per QALY gained as 31 717 (95% CI: 19 760–61 316). Cost-effectiveness was influenced most by ICD efficacy, time to replacement, utility, and patient age at implantation.
Conclusion: In a European healthcare setting, prophylactic ICD implantation may be cost-effective if current guidelines for patients with a reduced LVEF are followed.
Key Words: Cost-effectiveness analysis, Decision analytic model, Europe, Prophylactic implantable cardioverter defibrillator, Sudden death, Left ventricular ejection fraction
* Corresponding author. Tel: +44 207 351 8856, Fax: +44 207 351 8148, Email: m.cowie{at}imperial.ac.uk
Manuscript submitted 24 November 2008. Accepted after revision 2 March 2009.
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