Cost-effectiveness of cardiac resynchronization therapy in the MADIT-CRT trial

Cost Effectiveness of MADIT-CRT. Background: The Multicenter Automatic Defibrillator Implantation Trial-Cardiac Resynchronization Therapy (MADIT-CRT) trial demonstrated that cardiac resynchronization therapy (CRT) when added to the implantable cardiac defibrillator (ICD) reduces risk of heart failure or death in minimally symptomatic patients with reduced cardiac ejection fraction and wide QRS complex. Objectives: To evaluate 4-year cost-effectiveness of CRT-ICD compared to ICD alone using MADIT-CRT data. Research Design: Patients enrolled in the trial were randomized to implantation of either ICD or CRT-ICD in a 2:3 ratio, with up to 4-year follow-up period. Cost-effectiveness analyses were conducted, and sensitivity analyses by age, gender, and left bundle branch block (LBBB) conduction pattern were performed. Subjects: A total of 1,271 patients with ICD or CRT-ICD (US centers only) who reported healthcare utilization and health-related quality of life data. Measures: We used the EQ-5D (US weights) to assess patient HRQOL and translated utilization data to costs using national Medicare reimbursement rates. Results: Average 4-year healthcare expenditures in CRT-ICD patients were higher than costs of ICD patients ($62,600 vs 57,050, P = 0.015), mainly due to the device and implant-related costs. The incremental cost-effectiveness ratio of CRT-ICD compared to ICD was $58,330/quality-adjusted life years (QALY) saved. The cost effectiveness improved with longer time horizon and for the LBBB subgroup ($7,320/QALY), with no cost-effectiveness benefit being evident in the non-LBBB group. Conclusions: In minimally symptomatic patients with low ejection fraction and LBBB, CRT-ICD is cost effective within 4-year horizon when compared to ICD-only.