Yes to cardiac devices. But at what cost?

This editorial refers to ‘Cost-of-illness study of patients subjected to cardiac rhythm management devices implantation: results from a single tertiary centre’ by J. Fanourgiakis et al., on page 366

We are the fortunate witnesses of a relentless progress in clinical electrophysiology and device therapy. This has mainly been attributable to refinements in ablation techniques for atrial fibrillation and other arrhythmias as well as the development of cardiac resynchronization therapy and implantable cardioverter-defibrillator (ICD) therapy. The proven clinical benefits of these therapies have led to their inclusion in clinical guidelines and their application to an increasingly wide patient group.

The benefit of cardiac rhythm management device (CDRM) therapy comes at a cost, which includes a high device cost, an expensive implantation procedure, and a hospitalization. At a time when money is short and healthcare costs are being scrutinized by government, it is appropriate to ask whether CDRMs are affordable. Increasingly, this question is being directed not only at commissioners but also, to secondary care and primary care doctors. To answer this question, we must rely on economic evaluations.

Cost of illness (COI) was the first technique used in health economics.¹ It provides a monetary estimate for the economic burden of a disease or condition, in terms of medical expenses and employment compensation that are foregone as a result of illness or death. In essence, a COI is a useful description of the economic burden of a disease or condition to society, With COIs, policymakers can estimate the magnitude of economic flows associated with particular policy decisions. Despite its critics, COI studies are useful in calculating the resources needed to support a given intervention. For this reason, COI studies are still used by organizations such as the World Health Organization, the World Bank, and the National Institutes of Health. They should not be confused with cost–benefit analyses, insofar as they do not compare costs with outcomes.

In this issue of the Journal, Fanourgiakis et al.² present a study of the costs of implantation, hospitalization, and follow-up in patients undergoing pacemaker and ICD therapy. In a single-centre, prospective study, the authors address COI in 464 consecutive patients (370 pacemakers and 94 ICDs) followed-up for 12 months. A salient feature of this study is the inclusion of indirect costs attributable to the patient's productivity lost due to absence from work. The mean ‘upfront’ costs, including procedure, hospitalization, tests, and indirect costs were €3926 for pacemakers and €17 764 for ICDs. Thereafter, mean annual costs of therapy (direct and indirect) were €1816 for pacemaker therapy and €2819 for ICD therapy. Interestingly, the direct, annual health care cost of pacemaker patients was mainly attributable to medication (60%), followed by laboratory tests and imaging (22.2%). Similarly, the direct, annual health care cost of ICD patients was mainly driven by medication (69%) and hospitalization (24%).

On the basis of this study, the cost of CRDM would appear to be modest in comparison with other conditions. For example, the total estimated annual costs of chronic stable angina has been calculated at €29 972 (CAN$19 209) per patient.³ For lung cancer in the USA, the average cost per patient is €20 289 (1996 US$ 26 042) in the initial 3 months following diagnosis, €8823 (1996 US$11 325) thereafter and €23 460 (1996 US$30 563) in the terminal phase.⁴ The total costs of medical services for surviving colorectal cancer patients is €109 977 (1996 US $141 160). A comparison with other conditions was outside the scope of the present study but, on the basis of these comparisons, the authors are right to argue that the economic burden of the CRMDs is relatively low.

The authors also comment on the ‘upfront’ costs of CRDMs. In this respect, CRDM therapy is similar to operations, insofar as it is expensive to deliver and its clinical effects are realized over the long-term. In economic evaluations, it is therefore important to adopt a lifetime horizon. This, however, is rarely possible in the field of CRDM, particularly as the therapy itself changes over the years. Fanourgiakis et al. have only addressed a 12-month follow-up period and have not modelled the COI for the patient's lifetime. It is likely that a longer follow-up would lead to a lower COI.

As the authors argue, this COI study may be useful in estimating the total expenditure required for adequate CRMD implantation across Europe. The study was undertaken from the perspective of a public health system and therefore, it is likely to be generalizable to other countries. Estimates based on COIs such as this may be useful in assessing how much it would take to make the delivery of CRDMs more heterogenous across Europe.⁵

This paper is testament to the increasing commitment of electrophysiologists and device specialists to health economics. Even when times are hard, our primary concern as doctors should still be with the individual patient. For the benefit of Medicine and society as a whole we must, however, take an active part in the health economics debate.

Conflict of interest: F.L. has held consultancies with and received research funding from Medtronic Inc. and Sorin. He has also received research funding from St Jude Medical and advisory board fees from Boston Inc. He is also the co-chair of the Health Economic Committee, EHRA.

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