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

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. 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 Euro46 413. Estimated mean LY/QALY gained were 1.88/1.57, respectively. Probabilistic analysis estimated mean lifetime cost per QALY gained as Euro31 717 (95% CI: Euro19 760-Euro61 316). Cost-effectiveness was influenced most by ICD efficacy, time to replacement, utility, and patient age at implantation. In a European healthcare setting, prophylactic ICD implantation may be cost-effective if current guidelines for patients with a reduced LVEF are followed.