Authors' objectives:

This report aims to review the use of ICDs at the MUHC. The request is the result of the following situation. The effectiveness of ICDs in the secondary prevention of sudden death in certain defined patient groups has been well demonstrated. However, in March, 2002 the Multicenter Automatic Defibrillator Implantation Trial II (MADIT II) published the results of a study which indicated that the ICD could effectively prevent sudden death in a much larger group of patients than those previously identified. These instruments are relatively expensive and the economic impact of accepting the expanded indications for ICD use would be considerable. The following report will address three issues:

1) The strength of the evidence extending the indications for ICD use reported in the MADIT II study.

2) The potential health and economic impact of adopting the extended (MADIT II) indications in the MUHC.

3) The most appropriate policy for the MUHC in light of the above information.

Authors' recommendations: The TAU Committee notes that to take a policy decision that will significantly influence health outcomes and hospital budget should, whenever possible, be supported by more substantial evidence of outcome over a longer follow-up than is presently available. Nevertheless, a decision must clearly be made in the absence of such evidence even if it is only to guide policy for the immediate future. In view of the above considerations the committee recommends at this time: 1. That the MUHC, if possible with other institutions, urgently present this problem to government with a request that they consider the provision of special funds to finance ICD acquisition. The ministry should be urged to take part in a decision that will, in the absence of special funding, necessitate either a significant reduction in hospital services or a refusal to provide patients with effective life saving therapy. 2. Until special funding becomes available, the committee feels that ICD use at the MUHC should not be unlimited. Accordingly, the MUHC should restrict the use of ICDs along the following lines: - In the current year funding should be increased from the 2002 level (which allowed for approximately 50 implants), by approximately 50 %. This would allow for 75 implants per year, using the more sophisticated device (costing approximately $22,000), or for a larger number, using the simplified single chamber devices (costing approximately $12,000), the choice to be made at the discretion of the cardiologists concerned. - Acceptance of this recommendation will result in an increase in expenditure on ICD therapy from the present approximately $1.2 million in 2002, to $1.8 million in 2003. Thereafter, if the same implant rate with constant prices and device longevity were assumed, expenditure on ICD therapy would increase each year, from $1.8 million in 2003 to $3.2 million within 15 years. However, such a scenario is unlikely both because of the probability of further reduction in price in the coming years, and the likelihood that better selection of subjects will substantially reduce the demand for implants. 3. Patients should not be permitted to purchase their ICDs or to pay for an upgrade of their ICD through use of private resources. It is recognized that the principle of not allowing patients to upgrade the health services they receive by use of their own funds has been breached in the case of optical lenses and special splinting materials. Nevertheless, the committee believes the principle of refusing to provide two level health-care is accepted MUHC policy at this time. The fact that it has been breached does not mean that it has to be abandoned. 4. ICD policy must be formally adopted by the MUHC. Any decision to restrict the use of ICDs would be taken for economic, not clinical, reasons. The responsibility for such a policy must therefore be clearly accepted by the institution. 5. These recommendations should be considered temporary and should be subject to review, with amendment, when necessary. It is very likely that further reduction in the costs of the device or improvement in the hospitals budgetary situation could render these recommendations obsolete. Similarly, new research that will allow better identification of ICD candidates and give us more precise information on the extent of the benefits that these devices provide will require revision of these recommendations. Changes in any of these factors will necessitate review of these recommendations.

Authors' methods: Systematic review

Project Status: Completed

URL for project: http://www.mcgill.ca/tau/publications/2003

Year Published: 2003

English language abstract: An English language summary is available

Publication Type: Not Assigned

Country: Canada

Organisation Name: Technology Assessment Unit of the McGill University Health Centre (MUHC)

Contact Address: Technology Assessment Unit of the MUHC, 536-5100 Boul. Maisonneuve O, Montreal, H4A 3T2

Contact Name: eva.suarthana@mcgill.ca

Contact Email: nisha.almeida@muhc.mcgill.ca

Copyright: Technology Assessment Unit of the McGill University Health Centre (MUHC)