Goldberger Zachary, Elbel Brian, McPherson Craig A, Paltiel A David, Lampert Rachel
School of Medicine, Yale University, New Haven, Connecticut 06520, USA.
J Am Coll Cardiol. 2005 Sep 6;46(5):850-7. doi: 10.1016/j.jacc.2005.05.061.
The purpose of this study was to determine the least expensive strategy for device selection in patients receiving implantable cardioverter-defibrillators (ICDs).
Device cost for a single-chamber ICD is less than an atrioventricular (dual-chamber) ICD (AV-ICD); however, some patients without clinical need for AV-ICD at implantation might require a later upgrade, potentially offsetting the initial cost advantage of the single-chamber device.
Decision analysis was used to estimate expected resource utilization costs of three alternative implantation strategies: 1) single-chamber device in all, with later upgrade to AV-ICD if needed; 2) initial implantation of an AV-ICD in all; and 3) targeted device selection on the basis of results of electrophysiologic testing (presence or absence of induced bradyarrhythmias or atrial arrhythmias). Clinical base estimates were obtained from retrospective review of all patients receiving ICDs between June 1997 and July 2001 at a single university hospital. Economic inputs were collected from national and single-center sources.
In patients without other indications for electrophysiologic study (EPS), the expected per-person cost was least with the strategy of universal initial AV-ICD implantation (36,232 dollars) compared with initial single-chamber ICD/upgrade as needed (39,230 dollars) or EPS-guided selection (41,130 dollars). Sensitivity analyses demonstrated that universal AV-ICD implantation remained least expensive with upgrade rates as low as 10%. At a 5% upgrade rate, AV-ICD remained cheapest if the device cost-differential narrowed to 1,568 dollars. For patients undergoing EPS for risk assessment, EP-guided selection was least expensive.
The strategy of universal AV-ICD implantation, which provides the benefits of dual-chamber capability while obviating any potential need for future upgrade, is the least costly strategy for most patient populations receiving ICDs.
本研究旨在确定接受植入式心脏复律除颤器（ICD）患者选择设备的成本最低策略。
单腔ICD的设备成本低于房室（双腔）ICD（AV-ICD）；然而，一些在植入时无临床需求使用AV-ICD的患者可能随后需要升级，这可能抵消单腔设备最初的成本优势。
采用决策分析来估计三种替代植入策略的预期资源利用成本：1）全部使用单腔设备，必要时随后升级为AV-ICD；2）全部初始植入AV-ICD；3）根据电生理测试结果（是否诱发缓慢性心律失常或房性心律失常）进行有针对性的设备选择。临床基础估计值来自对1997年6月至2001年7月在一家大学医院接受ICD治疗的所有患者的回顾性研究。经济投入从国家和单中心来源收集。
在没有其他电生理检查（EPS）指征的患者中，与按需初始植入单腔ICD/升级（39,230美元）或EPS引导选择（41,130美元）相比，普遍初始植入AV-ICD的策略（36,232美元）预期人均成本最低。敏感性分析表明，升级率低至10%时，普遍植入AV-ICD仍然成本最低。升级率为5%时，如果设备成本差异缩小至1,568美元，AV-ICD仍然最便宜。对于因风险评估而接受EPS的患者，EPS引导选择成本最低。
普遍植入AV-ICD的策略，既提供了双腔功能的益处，又消除了未来升级的任何潜在需求，是大多数接受ICD治疗患者群体中成本最低的策略。
