CRT-Ds Are Cost-Effective in Patients With Class 2 or 3 HF

TORONTO — Using data from the Resynchronization/Defibrillation for Ambulatory Heart Failure (RAFT) trial of patients with mildly symptomatic heart failure, researchers determined that cardiac resynchronization therapy defibrillators (CRT-Ds) provide better value than implantable cardioverter defibrillators (ICDs) [1].

"Overall, CRT-D is cost-effective for patients eligible for the RAFT trial," said Dr George Wells (University of Ottawa Heart Institute, ON), presenting the results at a late-breaking-trial session here at the Canadian Cardiovascular Congress 2012 .

"We are finding an incremental cost-effectiveness ratio [of about Can$29 000, or US$33 000], which is far below $50 000, the benchmark for [a healthcare intervention] being economically attractive," Wells told heartwire .

Patients were eligible for RAFT if they had NYHA class 2 or 3 heart failure, left ventricular ejection fraction <30%, and a QRS duration >120 ms (or paced QRS >200 ms). RAFT randomized 894 patients to CRT-D and 904 patients to ICD and followed them for an average of 40 months.

Compared with patients implanted with an ICD, those who received a CRT-D had lower rates of the primary outcome of death or heart-failure hospitalization (hazard ratio 0.75), as was presented at the AHA meeting in 2010 and reported by heartwire.

"The AHA identified CRT-D as one of the top 10 cardiovascular advances in 2010," Wells said. "After we showed effectiveness, the next step was to say, 'Can we afford it?' These statistics basically say, 'Yes, it is cost-effective.' "

Using a Markov model with a 40-year time horizon, the researchers input cost-related data (such as hospitalizations or device replacements) and quality-of-life data (based on EQ-5D questionnaire replies) from the patients in RAFT. They used Ontario prices for items such as physician fees, drug costs, and cost of long-term care.

They found that the CRT-D cost $19 699 more than the ICD, but it also resulted in 0.870 more life-years.

More important, this device increased the quality of the added years: the difference in quality-adjusted life-years (QALYs) with CRT-D vs ICD was 0.663 (which is high, said Wells).

By comparison, the difference in QALY for common cardiac procedures ranges from 0.03 (for clopidogrel vs aspirin for secondary prevention after PCI) to 0.64 (for warfarin vs aspirin for stroke prevention in atrial fibrillation).

The incremental cost-effectiveness--obtained by dividing the difference in cost ($19 699) by the difference in QALY (0.663)--was Can$29 689.

This is less than the upper limit of US$50 000 per QALY--a commonly accepted benchmark for determining whether a healthcare intervention is cost-effective.

Comparable Results With US Costs

The reported Canadian findings were similar to earlier results the group had obtained using the same model but with US costs.

In the US cost analysis, the use of a CRT-D led to an average cost increase of $35 308, an average increase of 1.07 QALYs, and an incremental cost of $33 025 per QALY gained.

The researchers plan to publish a paper presenting their findings using both Canadian and American costs.

"Important Practical Implications"

To put these results into perspective, the cost of the improved quality of life with the CRT-D was lower than costs associated with other common cardiac procedures.

For example, the following costs per QALY have been reported: $115 000 for therapeutic hypothermia, $62 000 for transcatheter aortic-valve replacement, and $56 000 for LVAD placement for end-stage heart failure.

According to Wells, the current study has practical implications, since heart failure is becoming more prevalent in an aging population and funding bodies need to decide which devices to pay for. "There's a lot of class 2 patients, so this device will have widespread use, and now we know it will have cost-effective use as well," he said.

Commenting to heartwire after the session, comoderator Dr John Mancini (St Paul's Hospital, Vancouver, BC) said that this is a potentially practice-altering study. In a time of worldwide economic crises, stakeholders are more conscious of looking at costs vs benefits of treatments. For the ever-growing population of patients with heart failure, "we want to be as efficient as possible, so this apparent difference between one type of [device] and another is important," he said.

"This type of analysis is really important," echoed Dr Mario Talajic (Montreal Heart Institute, QC), "[and] I think that this is going to be useful to convince people--not just doctors but also healthcare administrators--that in certain patient subgroups [CRT-D] is extremely cost-effective.'"

RAFT was supported by the Canadian Institutes of Health Research and Medtronic of Canada.