Postgraduate Program in Cardiology and Cardiovascular Sciences, Federal University of Rio Grande do Sul, Porto Alegre, Brazil.
Heart Failure and Cardiac Transplantation Unit, Cardiovascular Division of Hospital de Clínicas de Porto Alegre, Brazil; Postgraduate Program in Cardiology and Cardiovascular Sciences, Medical School of the Federal University of Rio Grande do Sul, Porto Alegre, Brazil.
Int J Cardiol. 2013 Mar 10;163(3):309-315. doi: 10.1016/j.ijcard.2011.06.046. Epub 2011 Jun 24.
Cardiac resynchronization therapy (CRT) improves symptoms and survival in patients with heart failure (HF). However, the devices used to deliver it are costly and can impose a significant burden to the relatively constrained health budgets of middle-income countries such as Brazil.
A Markov model was constructed, representing the follow-up of a hypothetical cohort of HF patients, with a 20-year time horizon. Input data were based on information from a Brazilian cohort of 316 HF patients, as well as meta-analyses of data on devices' effectiveness and risks. Stochastic and probabilistic sensitivity analyses were performed for all important variables in the model. Costs were expressed as International Dollars (Int$), by application of current purchasing power parity conversion rate.
In the base-case analysis, the incremental cost-effectiveness ratio (ICER) of CRT over medical therapy was Int$ 15,723 per quality-adjusted life years (QALYs) gained. For CRT combined with an implantable cardioverter-defibrillator (ICD), ICER was Int$ 36,940/QALY over ICD alone, and Int$ 84,345/QALY over CRT alone. Sensitivity analyses showed that the model was generally robust, though susceptible to the cost of the devices, their impact on HF mortality, and battery longevity.
CRT is cost-effective for HF patients in the Brazilian public health system scenario. In patients eligible for CRT, upgrade to CRT+ICD has an ICER above the World Health Organization willingness-to-pay threshold of three times the nation's Gross Domestic Product per Capita (Int$ 31,689 for Brazil). However, for ICD eligible patients, upgrade to CRT+ICD is marginally cost-effective.
心脏再同步治疗（CRT）可改善心力衰竭（HF）患者的症状和生存率。然而，用于提供这种治疗的设备成本高昂，可能会给巴西等中等收入国家相对有限的卫生预算带来重大负担。
构建了一个马尔可夫模型，代表了一个假设的 HF 患者队列的随访，时间跨度为 20 年。输入数据基于 316 名 HF 患者的巴西队列信息以及设备有效性和风险的荟萃分析。对模型中的所有重要变量进行了随机和概率敏感性分析。成本表示为国际元（Int$），通过应用当前的购买力平价转换率。
在基本分析中，CRT 相对于药物治疗的增量成本效益比（ICER）为每获得一个质量调整生命年（QALY）增加 15723 国际元。对于 CRT 联合植入式心脏复律除颤器（ICD），与单独使用 ICD 相比，ICER 为 36940 国际元/QALY，与单独使用 CRT 相比，ICER 为 84345 国际元/QALY。敏感性分析表明，该模型总体上具有稳健性，但易受设备成本、对 HF 死亡率的影响以及电池寿命的影响。
在巴西公共卫生系统的情况下，CRT 对 HF 患者具有成本效益。在符合 CRT 条件的患者中，升级为 CRT+ICD 的增量成本效益比（ICER）高于世界卫生组织对支付意愿的阈值，即该国人均国内生产总值的三倍（巴西为 31689 国际元）。然而，对于符合 ICD 条件的患者，升级为 CRT+ICD 则具有轻微的成本效益。
