Jared P Beller1, Zachary Tyerman2, J Hunter Mehaffey2, Robert B Hawkins2, Eric J Charles2, Leora T Yarboro2, Nicholas R Teman2, Tanya Wancheck3, Gorav Ailawadi2, Nishaki K Mehta4. 1. Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia. Electronic address: jbeller@virginia.edu. 2. Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia. 3. Public Health Sciences, University of Virginia School of Medicine, Charlottesville, Virginia. 4. Division of Cardiovascular Medicine, Department of Medicine, University of Virginia, Charlottesville, Virginia.
Abstract
BACKGROUND: A significant percentage of patients who acutely develop high-grade atrioventricular block after valve surgery will ultimately recover, yet the ability to predict recovery is limited. The purpose of this analysis was to evaluate the cost-effectiveness of two different management strategies for the timing of permanent pacemaker implantation for new heart block after valve surgery. METHODS: A cost-effectiveness model was developed using costs and probabilities of short- and long-term complications of pacemaker placement, short-term atrioventricular node recovery, intensive care unit stays, and long-term follow-up. We aggregated the total expected cost and utility of each option over a 20-y period. Quality-adjusted survival with a pacemaker was estimated from the literature and institutional patient-reported outcomes. Primary decision analysis was based on an expected recovery rate of 36.7% at 12 d with timing of pacemaker implantation: early placement (5 d) versus watchful waiting for 12 d. RESULTS: A strategy of watchful waiting was more costly ($171,798 ± $45,695 versus $165,436 ± $52,923; P < 0.0001) but had a higher utility (9.05 ± 1.36 versus 8.55 ± 1.33 quality-adjusted life years; P < 0.0001) than an early pacemaker implantation strategy. The incremental cost-effectiveness ratio of watchful waiting was $12,724 per quality-adjusted life year. The results are sensitive to differences in quality-adjusted survival and rates of recovery of atrioventricular node function. CONCLUSIONS: Watchful waiting for pacemaker insertion is a cost-effective management strategy compared with early placement for acute atrioventricular block after valve surgery. Although this is cost-effective from a population perspective, clinical risk scores predicting recovery will aid in personalized decision-making.
BACKGROUND: A significant percentage of patients who acutely develop high-grade atrioventricular block after valve surgery will ultimately recover, yet the ability to predict recovery is limited. The purpose of this analysis was to evaluate the cost-effectiveness of two different management strategies for the timing of permanent pacemaker implantation for new heart block after valve surgery. METHODS: A cost-effectiveness model was developed using costs and probabilities of short- and long-term complications of pacemaker placement, short-term atrioventricular node recovery, intensive care unit stays, and long-term follow-up. We aggregated the total expected cost and utility of each option over a 20-y period. Quality-adjusted survival with a pacemaker was estimated from the literature and institutional patient-reported outcomes. Primary decision analysis was based on an expected recovery rate of 36.7% at 12 d with timing of pacemaker implantation: early placement (5 d) versus watchful waiting for 12 d. RESULTS: A strategy of watchful waiting was more costly ($171,798 ± $45,695 versus $165,436 ± $52,923; P < 0.0001) but had a higher utility (9.05 ± 1.36 versus 8.55 ± 1.33 quality-adjusted life years; P < 0.0001) than an early pacemaker implantation strategy. The incremental cost-effectiveness ratio of watchful waiting was $12,724 per quality-adjusted life year. The results are sensitive to differences in quality-adjusted survival and rates of recovery of atrioventricular node function. CONCLUSIONS: Watchful waiting for pacemaker insertion is a cost-effective management strategy compared with early placement for acute atrioventricular block after valve surgery. Although this is cost-effective from a population perspective, clinical risk scores predicting recovery will aid in personalized decision-making.
Authors: Uwe K H Wiegand; Frank Bode; Hendrik Bonnemeier; Frank Eberhard; Monika Schlei; Werner Peters Journal: Pacing Clin Electrophysiol Date: 2003-10 Impact factor: 1.976
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Authors: Fred M Kusumoto; Mark H Schoenfeld; Coletta Barrett; James R Edgerton; Kenneth A Ellenbogen; Michael R Gold; Nora F Goldschlager; Robert M Hamilton; José A Joglar; Robert J Kim; Richard Lee; Joseph E Marine; Christopher J McLeod; Keith R Oken; Kristen K Patton; Cara N Pellegrini; Kimberly A Selzman; Annemarie Thompson; Paul D Varosy Journal: J Am Coll Cardiol Date: 2018-11-06 Impact factor: 24.094
Authors: J Hunter Mehaffey; Nathan S Haywood; Robert B Hawkins; John A Kern; Nicholas R Teman; Irving L Kron; Leora T Yarboro; Gorav Ailawadi Journal: Ann Thorac Surg Date: 2018-03-22 Impact factor: 4.330