Device implants cost-effective, prolong survival in HF patients

Real-world evidence supports trial data and suggests that the use of implantable cardioverter-defibrillator (ICD) and/or cardiac resynchronization therapy (CRT) devices are clinically sound and cost-effective, according to a recent study.

Drawing from England’s national hospital administrative database, the researchers identified 5,512 and 3,528 patients with a first implantation of CRT and ICD, respectively, as well as 265,519 patients first admitted for heart failure (HF) without any device implants. Device patients tended to be younger and more predominantly male than typical HF admissions; comorbidities were common and occurred at comparable frequencies across groups.

Within 5 years, 67.6 percent of the no-device HF patients died. In comparison, mortality rates for both the CRT (41.8 percent) and ICD (35.9 percent) groups were substantially lower. [ESC Heart Fail 2021;doi:10.1002/ehf2.13357]

Median survival time was 2,282 days among patients with the CRT device and 2,478 days among those with an ICD implant. Log-rank analysis revealed a significant difference between the two device groups (p<0.001). Notably, HF accounted for less than a third of the deaths in both CRT (27.5 percent) and ICD (31.0 percent) groups.

In terms of hospital activity, Poisson regression showed that total admission rates for both inpatient and day cases fell in the CRT and ICD groups, though the change for the latter was small. In both groups, the peak emergency department visits occurred during the index month and declined thereafter.

In turn, only CRT recipients saw a substantial decrease in the mean cost per patient at risk; the drop in costs among ICD patients was slight. Outpatient appointment costs per patient at risk, on the other hand, increased in all groups.

Notably, comparing total costs for all hospital activity—emergency, outpatient, and admissions—in the year before vs after the index month showed that only CRT patients recorded a drop in expenditure; those implanted with ICDs saw an almost GBP 700 increase in costs.

Similarly, complications and device replacements occurred more frequently in the CRT vs ICD groups.

“The debate continues regarding the applicability of real-world observational data on estimating the clinical and cost-effectiveness of therapy due to concerns around selection bias, coding quality, and missing data,” the researchers said. “However, RCTs are highly protocol-driven environments where populations are carefully selected and cared for and therefore tend to have a better outcome than less selected patients.”

The present study found real-world rates of clinical efficacy, cost-effectiveness, mortality, and complications comparable to those in previously published RCTs, supporting policy decisions to recommend the use of CRTs and ICDs for patients most likely to benefit from them, they added.