Cost-effectiveness of cardiac resynchronization therapy in patients with heart failure: The perspective of a middle-income country's public health system

BackgroundCardiac 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.MethodsA 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$), by application of current purchasing power parity conversion rate.ResultsIn the base-case analysis, the incremental cost-effectiveness ratio (ICER) of CRT over medical therapy was Int$ 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.ConclusionsCRT 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.

Research highlights► Cardiac resynchronization therapy (CRT) is an effective, but costly strategy. ► CRT may be a cost-effective therapy for heart failure in middle-income countries. ► More expensive (combination) devices did not meet WHO cost-effectiveness threshold. ► The results are sensitive to the cost of the devices and battery longevity. ► Price negotiation between policy makers and manufacturers can turn other devices more attractive.