Long-term cost-effectiveness of alternative management strategies for patients with life-threatening ventricular arrhythmias. Electrophysiologic Study versus Electrocardiographic Monitoring (ESVEM) Investigators.

BACKGROUND Serial antiarrhythmic drug testing guided by Holter monitoring and electrophysiologic study had similar clinical outcomes in the Electrophysiologic Study versus Electrocardiographic Monitoring (ESVEM) trial, while patients treated with sotalol had improved outcomes. The purpose of this study was to compare long-term cost-effectiveness of these management alternatives. METHODS Patients in the ESVEM trial were linked to computerized files of either the Health Care Finance Administration or the Department of Veterans Affairs. Total hospital costs and survival time over five year follow-up were measured using actuarial methods, and cost-effectiveness was calculated. RESULTS Patients randomized to therapy guided by electrophysiologic study had more hospital admissions, higher costs, and a cost-effectiveness ratio of $162,500 per life year added compared with therapy guided by Holter monitoring. Patients randomized to sotalol had fewer hospitalizations, lower costs, and better survival than patients randomized to other drugs, and sotalol was a dominant strategy in the cost-effectiveness analysis. Patients for whom an effective drug was found had fewer hospital admissions, lower costs, and longer survival. These findings were robust in sensitivity analyses and in bootstrap replications. CONCLUSIONS Serial drug testing guided by electrophysiologic study had an unfavorable cost-effectiveness ratio relative to Holter monitoring, while sotalol was cost-effective relative to other antiarrhythmic drugs.

[1]  E. Keeler,et al.  Discounting of Life-Saving and Other Nonmonetary Effects , 1983 .

[2]  D. Wyse,et al.  A randomized clinical trial of the noninvasive and invasive approaches to drug therapy of ventricular tachycardia. , 1987, The New England journal of medicine.

[3]  R. Tibshirani,et al.  An introduction to the bootstrap , 1993 .

[4]  A. Detsky,et al.  A clinician's guide to cost-effectiveness analysis. , 1990, Annals of internal medicine.

[5]  V. Berridge.  Health and medicine , 1990 .

[6]  J. Mason.  A comparison of electrophysiologic testing with Holter monitoring to predict antiarrhythmic-drug efficacy for ventricular tachyarrhythmias. Electrophysiologic Study versus Electrocardiographic Monitoring Investigators. , 1993, The New England journal of medicine.

[7]  D. Hedeker,et al.  Impacts of foot orthoses on pain and disability in rheumatoid arthritics. , 1996, Journal of clinical epidemiology.

[8]  Ruth Etzioni,et al.  Estimating the costs attributable to a disease with application to ovarian cancer. , 1996, Journal of clinical epidemiology.

[9]  S. Yusuf,et al.  Effect of amiodarone on mortality after myocardial infarction: a double-blind, placebo-controlled, pilot study. , 1992, Journal of the American College of Cardiology.

[10]  B Efron,et al.  Statistical Data Analysis in the Computer Age , 1991, Science.

[11]  E. Platia,et al.  Automatic implantable cardioverter-defibrillator: is early implantation cost-effective? , 1990, Journal of the American College of Cardiology.

[12]  J Lipscomb,et al.  Comparison of analytic models for estimating the effect of clinical factors on the cost of coronary artery bypass graft surgery. , 1993, Journal of clinical epidemiology.

[13]  S. Connolly,et al.  Post‐Myocardial Infarction Mortality in Patients With Ventricular Premature Depolarizations: Canadian Amiodarone Myocardial Infarction Arrhythmia Trial Pilot Study , 1991, Circulation.

[14]  K McPherson,et al.  Mortality and reoperation after open and transurethral resection of the prostate for benign prostatic hyperplasia. , 1989, The New England journal of medicine.

[15]  H. Greene.  Randomized antiarrhythmic drug therapy in survivors of cardiac arrest (the CASCADE Study). The CASCADE Investigators. , 1993, The American journal of cardiology.

[16]  L. Wilkins.  Determinants of Predicted Efficacy of Antiarrhythmic Drugs in the Electrophysiologic Study Versus Electrocardiographic Monitoring Trial , 1993 .

[17]  M. Drummond,et al.  Health Care Technology: Effectiveness, Efficiency and Public Policy@@@Methods for the Economic Evaluation of Health Care Programmes , 1988 .

[18]  Thomas C. Chalmers,et al.  Economic Analysis in Randomized Control Trials , 1992, Medical care.

[19]  J. Ruskin,et al.  An analysis of the cost effectiveness of the implantable defibrillator. , 1990, Circulation.

[20]  C Anderson,et al.  Measuring what works in health care. , 1994, Science.

[21]  W. Roper,et al.  Effectiveness in Health Care , 1988 .

[22]  D. Wyse,et al.  Drug therapy of ventricular tachycardia: a cost comparison of randomized noninvasive and invasive approaches. , 1992, The Canadian journal of cardiology.

[23]  G. Larsen,et al.  Cost-effectiveness of the implantable cardioverter-defibrillator: effect of improved battery life and comparison with amiodarone therapy. , 1992, Journal of the American College of Cardiology.

[24]  A. L. Hillman,et al.  Economic Analysis of Health Care Technology: A Report on Principles , 1995, Annals of Internal Medicine.

[25]  J. Mason,et al.  Cost of initial therapy in the Electrophysiological Study Versus ECG Monitoring trial (ESVEM). , 1995, Circulation.

[26]  J. Mason.  A comparison of seven antiarrhythmic drugs in patients with ventricular tachyarrhythmias. Electrophysiologic Study versus Electrocardiographic Monitoring Investigators. , 1993, The New England journal of medicine.

[27]  Jeffrey L. Anderson,et al.  The ESVEM Trial: Electrophysiologic Study Versus Electrocardiographic Monitoring for Selection of Antiarrhythmic Therapy of Ventricular Tachyarrhythmias , 1989, Circulation.

[28]  M. Weinstein,et al.  Foundations of cost-effectiveness analysis for health and medical practices. , 1977, The New England journal of medicine.