Children's Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
Children's Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio.
Heart Rhythm. 2020 Feb;17(2):287-293. doi: 10.1016/j.hrthm.2019.08.028. Epub 2019 Aug 30.
Dilated cardiomyopathy (DCM) is the most common cardiomyopathy in children. Patients with severe cardiac dysfunction are thought to be at risk of sudden cardiac arrest (SCA). After diagnosis, a period of medical optimization is recommended before permanent implantable cardioverter-defibrillator (ICD) implantation. Wearable cardioverter-defibrillators (WCDs) provide an option for arrhythmia protection as an outpatient during this optimization.
The purpose of this study was to determine the strategy that optimizes cost and survival during medical optimization of a patient with DCM before ICD placement.
A Markov state transition model was constructed for the 3 clinical approaches to compare costs, clinical outcomes, and quality of life: (1) "Inpatient," (2) "Home-WCD," and (3) "Home-No WCD." Transitional probabilities, costs, and utility metrics were extracted from the existing literature. Cost-effectiveness was assessed comparing each paradigm's incremental cost-effectiveness ratio against a societal willingness-to-pay threshold of $50,000 per quality-adjusted life year.
The cost-utility analysis illustrated that Home-WCD met the willingness-to-pay threshold with an incremental cost-effectiveness ratio of $20,103 per quality-adjusted life year and 4 mortalities prevented per 100 patients as compared with Home-No WCD. One-way sensitivity analyses demonstrated that Home-No WCD became the most cost-effective solution when the probability of SCA fell below 0.2% per week, the probability of SCA survival with a WCD fell below 9.8%, or the probability of SCA survival with Home-No WCD quadrupled from base-case assumptions.
Based on the existing literature probabilities of SCA in pediatric patients with DCM undergoing medical optimization before ICD implantation, sending a patient home with a WCD may be a cost-effective strategy.
扩张型心肌病（DCM）是儿童中最常见的心肌病。严重心功能障碍的患者被认为有发生心源性猝死（SCA）的风险。诊断后，建议在植入永久性植入式心脏复律除颤器（ICD）之前进行一段时间的医疗优化。在这段优化期间，佩戴式心脏复律除颤器（WCD）为患者提供了一种作为门诊患者进行心律失常保护的选择。
本研究旨在确定在 DCM 患者植入 ICD 之前进行医疗优化期间，哪种策略可以优化成本和生存。
为比较 3 种临床方法的成本、临床结局和生活质量，构建了一个马尔可夫状态转移模型：（1）“住院”，（2）“家庭-WCD”，（3）“家庭-无 WCD”。从现有文献中提取转移概率、成本和效用指标。通过比较每种方案的增量成本效益比与社会愿意支付的 5 万美元/质量调整生命年阈值，评估成本效益。
成本效益分析表明，与家庭-无 WCD 相比，家庭-WCD 具有成本效益，增量成本效益比为每质量调整生命年 20103 美元，每 100 名患者可预防 4 例死亡。单因素敏感性分析表明，当 SCA 发生的概率每周低于 0.2%、WCD 对 SCA 存活的概率低于 9.8%或家庭-无 WCD 对 SCA 存活的概率比基本情况假设增加 4 倍时，家庭-无 WCD 成为最具成本效益的方案。
根据现有文献中 DCM 患者在植入 ICD 之前进行医疗优化时 SCA 的发生概率，让患者带 WCD 回家可能是一种具有成本效益的策略。
