This article is more than 5 years old. Information may no longer be current.
Repeat revisions for ICDs, CRT-Ds linked to substantial costs
When a patient with an implantable cardioverter defibrillator or a cardiac resynchronization therapy defibrillator undergoes more than one revision procedure, substantial costs are incurred, researchers reported in Circulation: Cardiovascular Quality and Outcomes.
Researchers sought to explore patterns of revisions and complications associated with ICD and CRT-D devices and to quantify and estimate the related costs.
Arnold Greenspon
“We were trying to get an idea of what the various factors are that are driving the cost,” researcher Arnold Greenspon, MD, professor of medicine and director of the cardiac electrophysiology laboratory at Thomas Jefferson University Hospital, Philadelphia, said in an interview. “One of the things we wanted to look at is what happens when someone gets their ICD [or CRT-D] battery changed. What are the costs involved, both of the device … [and any] complications afterward?”
Both ICDs and CRT-Ds use more energy and have shorter battery lives than pacemakers, but are often used in patients who are younger and sicker than those who receive pacemakers, Greenspon noted. “If you put a pacemaker battery into someone who’s a little over 70, and it lasts 10 years, they may undergo one battery change in their lifetime, whereas patients with ICDs and CRT-Ds, we find, are having multiple battery changes. We think that’s a likely risk factor for infection, which can be devastating,” he said.
Greenspon and colleagues analyzed data on 858 patients (567 with ICD, 291 with CRT-D) collected from the 5% Medicare Limited Data Set database. All patients were aged at least 65 years, were implanted in 2004 or 2005, survived for at least 8 years and underwent their first revision for a battery replacement only. Those with a primary implantation plus one revision (n = 615) were compared with those who had a primary implantation plus at least two revisions (n = 243, including 15 with at least one infection complication and 68 with at least one non-infection complication).
Approximately 80% of those with only one revision had it performed 4 to 6 years after implantation for CRT-Ds and 4 to 8 years after implantation for ICDs. For the group with more than one revision, approximately 50% had their first revision within 3.5 years for CRT-Ds and within 2.5 years for ICDs, according to the researchers.
Cumulative total costs per patient were higher for those who underwent more than one revision, Greenspon and colleagues found. Among those with CRT-Ds, the per-patient cumulative total cost was $189,000 with one revision, compared with $219,000 for those with more than one revision. Among patients with ICDs, the per-patient cumulative total cost was $177,000 for those with one revision, compared with $196,000 for those with more than one revision.
For patients who required more than one revision due to non-infection complications, cumulative total costs averaged $284,640 for those with CRT-Ds (51% of which were inpatient costs) and $235,550 for those with ICDs (56% of which were inpatient costs), according to the researchers. Data analysis on infections was considered exploratory due to the small number of patients.
Compared with those who had one revision, those with more than one were younger and more likely to have a Charlson comorbidity index score of at least 3, the researchers found.
Jordana Schmier
“We didn’t design this study to be predictive of revisions … [but] there’s a little bit of a trend of [patients with more than one revision] having more comorbidities,” Jordana Schmier, MA, senior managing scientist, health sciences for Exponent in Alexandria, Virginia, told Cardiology Today. “The Charlson comorbidity index … doesn’t hone in on any specific ones, but it’s an easy metric to use to get a sense of comorbidities. If we had a larger population, we could explore that further.”
Greenspon said the findings indicate that device companies must find ways to develop batteries for ICDs and CRT-Ds that last longer. “All the major companies have come to the conclusion that this is a big deal,” he said. “We’ll see more emphasis on this. What we try to teach is that if a patient is going to have a procedure, you want them to have only one procedure. The operation itself at the time of the procedure has a low risk, but you’re compounding that risk in the patient when they have their second, third or fourth. It’s not just additive; the curve is much steeper.”
This abstract was originally prepared for presentation at the American Heart Association’s Quality of Care and Outcomes Research Scientific Sessions, which was canceled due to protests and an ongoing state of emergency in Baltimore. – by Erik Swain