This Article Free upon publication Full Text Full Text (PDF) All Versions of this Article: 111/2/165    most recent 01.CIR.0000151810.69732.41v1 Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Rinfret, S. Articles by Goldman, L. Search for Related Content PubMed PubMed Citation Articles by Rinfret, S. Articles by Goldman, L. Related Collections Health policy and outcome research Pacemaker Arrhythmias, clinical electrophysiology, drugs

(Circulation. 2005;111:165-172.)
© 2005 American Heart Association, Inc.

Health Services and Outcomes Research

Cost-Effectiveness of Dual-Chamber Pacing Compared With Ventricular Pacing for Sinus Node Dysfunction

Stéphane Rinfret, MD, MSc; David J. Cohen, MD, MSc; Gervasio A. Lamas, MD; Kirsten E. Fleischmann, MD, MPH; Milton C. Weinstein, PhD; John Orav, PhD; Eleanor Schron, MS, RN; Kerry L. Lee, PhD; Lee Goldman, MD

From the Department of Medicine (S.R.), Centre Hospitalier de l’Université de Montréal (CHUM), University of Montreal, Montreal, Canada; the Department of Medicine (D.J.C.), Beth Israel–Deaconess Medical Center and Harvard Medical School, Boston, Mass; the Division of Cardiology (G.A.L.), Mount Sinai Medical Center and Miami Heart Institute, Miami Beach, Fla; the Department of Medicine (K.E.F., L.G.), University of California, San Francisco, Calif; the Center for Risk Analysis (M.C.W.), Harvard School of Public Health, Boston Mass; the Department of Medicine (J.O.), Brigham and Women’s Hospital and Harvard Medical School, Boston, Mass; the National Heart, Lung, and Blood Institute (E.S.), Bethesda, Md; and the Duke Clinical Research Institute and Duke University School of Medicine (K.L.L.), Durham, NC.

Reprint requests to David J. Cohen, MD, MSc, Beth Israel–Deaconess Medical Center, Cardiology Division, 330 Brookline Ave, Boston, MA 02215. E-mail dcohen{at}caregroup.harvard.edu

Received April 26, 2004; revision received September 13, 2004; accepted October 5, 2004.

Background— Compared with single-chamber ventricular pacing, dual-chamber pacing can reduce adverse events and, as a result, improve quality of life in patients paced for sick sinus syndrome. It is not clear, however, how these benefits compare with the increased cost of dual-chamber pacemakers.

Methods and Results— We used 4-year data from a 2010-patient, randomized trial to estimate the incremental cost-effectiveness of dual-chamber pacing compared with ventricular pacing and then projected these findings over the patients’ lifetimes by using a Markov model that was calibrated to the first 5 years of in-trial data. To assess the stability of the findings, we performed 1000 bootstrap analyses and multiple sensitivity analyses. During the first 4 years of the trial, dual-chamber pacemakers increased quality-adjusted life expectancy by 0.013 year per subject at an incremental cost-effectiveness ratio of $53 000 per quality-adjusted year of life gained. Over a lifetime, dual-chamber pacing was projected to increase quality-adjusted life expectancy by 0.14 year with an incremental cost-effectiveness ratio of $6800 per quality-adjusted year of life gained. In bootstrap analyses, dual-chamber pacing was cost-effective in 91.9% of simulations at a threshold of $50 000 per quality-adjusted year of life and in 93.2% of simulations at a threshold of $100 000. Its cost-effectiveness ratio was also below this threshold in numerous sensitivity analyses that varied key estimates.

Conclusions— For patients with sick sinus syndrome requiring pacing, dual-chamber pacing increases quality-adjusted life expectancy at a cost that is generally considered acceptable.

Key Words: pacing • pacemakers • sinoatrial node • cost-benefit analysis • quality of life

This article has been cited by other articles:

				P. E. Vardas, H. E. Mavrakis, and W. D. Toff CHAPTER 27 Bradycardia ESC Textbook of Cardiovascular Medicine, January 1, 2009; 2(1): med-9780199566990-chapter - med-9780199566990-chapter. [Abstract] [Full Text] [PDF]

				A. E. Epstein, J. P. DiMarco, K. A. Ellenbogen, N.A. M. Estes III, R. A. Freedman, L. S. Gettes, A. M. Gillinov, G. Gregoratos, S. C. Hammill, D. L. Hayes, et al. ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices) Developed in Collaboration With the American Association for Thoracic Surgery and Society of Thoracic Surgeons J. Am. Coll. Cardiol., May 27, 2008; 51(21): e1 - e62. [Full Text] [PDF]

				Writing Committee Members, A. E. Epstein, J. P. DiMarco, K. A. Ellenbogen, N.A. M. Estes III, R. A. Freedman, L. S. Gettes, A. M. Gillinov, G. Gregoratos, S. C. Hammill, et al. ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices): Developed in Collaboration With the American Association for Thoracic Surgery and Society of Thoracic Surgeons Circulation, May 27, 2008; 117(21): e350 - e408. [Full Text] [PDF]

				M. Brignole, F. Giada, A. Raviele, and J. J. Blanc Pacing for syncope: what role? which perspective? Eur. Heart J. Suppl., December 1, 2007; 9(suppl_I): I37 - I43. [Abstract] [Full Text] [PDF]

				Authors/Task Force Members, P. E. Vardas, A. Auricchio, J.-J. Blanc, J.-C. Daubert, H. Drexler, H. Ector, M. Gasparini, C. Linde, F. B. Morgado, et al. Guidelines for cardiac pacing and cardiac resynchronization therapy: The Task Force for Cardiac Pacing and Cardiac Resynchronization Therapy of the European Society of Cardiology. Developed in Collaboration with the European Heart Rhythm Association Europace, October 1, 2007; 9(10): 959 - 998. [Full Text] [PDF]

				Authors/Task Force Members, P. E. Vardas, A. Auricchio, J.-J. Blanc, J.-C. Daubert, H. Drexler, H. Ector, M. Gasparini, C. Linde, F. B. Morgado, et al. Guidelines for cardiac pacing and cardiac resynchronization therapy: The Task Force for Cardiac Pacing and Cardiac Resynchronization Therapy of the European Society of Cardiology. Developed in Collaboration with the European Heart Rhythm Association Eur. Heart J., September 2, 2007; 28(18): 2256 - 2295. [Full Text] [PDF]

				H.-F. Tse and C.-P. Lau Clinical Trials for Cardiac Pacing in Bradycardia: The End or the Beginning? Circulation, July 4, 2006; 114(1): 3 - 5. [Full Text] [PDF]

				J. S. Healey, W. D. Toff, G. A. Lamas, H. R. Andersen, K. E. Thorpe, K. A. Ellenbogen, K. L. Lee, A. M. Skene, E. B. Schron, J. D. Skehan, et al. Cardiovascular Outcomes With Atrial-Based Pacing Compared With Ventricular Pacing: Meta-Analysis of Randomized Trials, Using Individual Patient Data Circulation, July 4, 2006; 114(1): 11 - 17. [Abstract] [Full Text] [PDF]

				M. M. Scheinman and E. Keung The Year in Clinical Electrophysiology J. Am. Coll. Cardiol., March 21, 2006; 47(6): 1207 - 1213. [Full Text] [PDF]

				L. Goldman Cost-Effectiveness in a Flat World -- Can ICDs Help the United States Get Rhythm? N. Engl. J. Med., October 6, 2005; 353(14): 1513 - 1515. [Full Text] [PDF]

				H. M. Krumholz The Year in Epidemiology, Health Services, and Outcomes Research J. Am. Coll. Cardiol., October 4, 2005; 46(7): 1362 - 1370. [Full Text] [PDF]