Keeping Things in Perspective

The New York Times has an interesting piece in their Business section today on implantable cardiac defibrillators (ICDs), but paints a remarkably pessimistic view of the future market for the devices. While I do not argue with the fact that ICD implants nationally have declined, I think it's relatively important to compare the cost of ICDs relative to other therapies we dispense in medicine relative to their life-saving value to our healthcare system.

Although admittedly assembled by Medtronic (who has a vested interest in promoting ICD therapy and yes, I suppose I do, too), there are data of the costs of ICDs relative to other preventative therapies doctors provide as "prevention." Here's a slide from them that adds perspective:

Click image to enlarge

Additionally, although the SCD-HeFT trial demonstrated that 15 patients were needed to be treated before a life was saved, other trials demonstrated a significantly better odds at saving a life:

Click image to enlarge

MUSTT @ 5 years from Kaplan Meier (KM) curve: 55%-24%, NNT=3 N Engl J Med 1999;341:1882-1890
MADIT @ average follow-up of 2.4 yrs, crude mortality rate: 39%-16%, NNT=4 N Engl J Med. 1996;335:1933-1940
MADIT-II @ 3 years from KM curve: 31%-22%, NNT=11 N Engl J Med. 2002;346:877-883
AVID @ 3 years from the KM curve: 36%-25%, NNT=9 N Engl J Med. 1997;337:1576-1583
SAVE (captopril, an ACE inhibitor) crude rate with average follow-up of 42 months: 25%-20%, NNT=20 N Engl J Med, 1992; 327:669-677.
Merit-HF (metoprolol, a BB in HF patients) @ 1 year from KM curve: 11%-7.2%, NNT 26 LANCET 1999; 353:2001-07.
4S (simvastatin) @ 6 years from KM curve: 12.3%-8.7%, NNT=28 LANCET 1994; 344: 1383-1389.
Amiodarone Meta-analysis of 15 trial @ average follow-up of 2 years: 19.2%-16.5%, NNT=37 Circulation, 1997; 96: 2823-2829.


Finally, in terms of cost of other preventative therapies that our society has deemed useful to save a life, I always appreciated this view:

Click image to enlarge

Just trying to keep it in perspective.

-Wes