Should the implantable cardiac defibrillator be used for primary prevention of sudden death? A review of the issues relevant to hospital decision making.

摘要

BACKGROUND: New evidence suggests that the implantable cardiac defibrillator (ICD) may be effective for primary prevention of sudden death. High instrumental cost and the potentially large number of candidates will significantly impact hospital budgets. OBJECTIVE: To review the information relevant to hospital policy decisions on the use of ICDs for primary prevention. METHODS: Modelling based on an evaluation of reported studies and Canadian costs, detailed in a comprehensive review available at . RESULTS: Health outcomes: Two high-quality primary prevention trials suggest a reduction in annual mortality of 2.9% with bounds of probability (PB) of 2.0% to 3.8%, in early years. To undertake 100 implants per year may result in an increasing annual saving of life-years of acceptable quality, stabilizing by 15 years at 110 (PB 72 to 154) each year. Economic impact: The annual costs would stabilize at 15 years at approximately Dollars 4.3 million. Cost-effectiveness: Theincremental cost-effectiveness from the point of view of the health care system would be approximately Dollars 47,000 (PB Dollars 35,000 to Dollars 70,000), discounted at 3%. Ethical and legal issues: The decision should not be individual but institutional, using a process that is transparent, consistent and fair. CONCLUSIONS: The ICD can prolong life, with acceptable quality. Restriction of its use would be solely on grounds of expense.