Hadwiger Moritz, Frielitz Fabian-Simon, Eisemann Nora, Elsner Christian, Dagres Nikolaos, Hindricks Gerhard, Katalinic Alexander
Institute of Social Medicine and Epidemiology, University of Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany.
Heart Center Leipzig, University of Leipzig, Strümpellstr. 39, 04289, Leipzig, Germany.
Appl Health Econ Health Policy. 2021 Jan;19(1):57-68. doi: 10.1007/s40258-020-00571-y.
Cardiac resynchronisation therapy (CRT) is a well-established form of treatment for patients with heart failure and cardiac dyssynchrony. There are two different types of CRT devices: the biventricular pacemaker (CRT-P) and the biventricular defibrillator (CRT-D). The latter is more complex but also more expensive. For the majority of patients who are eligible for CRT, both devices are appropriate according to current guidelines. The purpose of this study was to conduct a cost-utility analysis for CRT-D compared to CRT-P from a German payer's perspective.
A cohort Markov-model was developed to assess average costs and quality-adjusted life-years (QALY) for CRT-D and CRT-P. The model consisted of six stages: one for the device implementation, one for the absorbing state death, and two stages ("Stable" and "Hospital") for either a CRT device or medical therapy. The time horizon was 20 years. Deterministic and probabilistic sensitivity analyses and scenario analyses were conducted.
The incremental cost-effectiveness ratio (ICER) of CRT-D compared with CRT-P was €24,659 per additional QALY gained. In deterministic sensitivity analysis, the survival advantage of CRT-D to CRT-P was the most influential input parameter. In the probabilistic sensitivity analysis 96% of the simulated cases were more effective but also more costly.
Therapy with CRT-D compared to CRT-P resulted in an additional gain of QALYs, but was more expensive. In addition, the ICER was subject to uncertainty, especially due to the uncertainty in the survival benefit. A randomised controlled trial and subgroup analyses would be desirable to further inform decision making.
心脏再同步治疗（CRT）是治疗心力衰竭和心脏不同步患者的一种成熟治疗方式。有两种不同类型的CRT设备：双心室起搏器（CRT-P）和双心室除颤器（CRT-D）。后者更复杂但也更昂贵。对于大多数符合CRT治疗条件的患者，根据当前指南，这两种设备都是合适的。本研究的目的是从德国医保支付方的角度对CRT-D与CRT-P进行成本效用分析。
建立了一个队列马尔可夫模型，以评估CRT-D和CRT-P的平均成本和质量调整生命年（QALY）。该模型由六个阶段组成：一个用于设备植入，一个用于吸收状态死亡，以及两个阶段（“稳定”和“住院”）用于CRT设备或药物治疗。时间跨度为20年。进行了确定性和概率敏感性分析以及情景分析。
与CRT-P相比，CRT-D的增量成本效益比（ICER）为每增加一个QALY获得24,659欧元。在确定性敏感性分析中，CRT-D相对于CRT-P的生存优势是最具影响力的输入参数。在概率敏感性分析中，96%的模拟病例更有效但也更昂贵。
与CRT-P相比，CRT-D治疗可带来额外的QALY增加，但成本更高。此外，ICER存在不确定性，尤其是由于生存获益的不确定性。需要进行一项随机对照试验和亚组分析，以进一步为决策提供信息。
