Author + information
- Received February 10, 1986
- Revision received June 2, 1986
- Accepted June 20, 1986
- Published online April 1, 1987.
- J. Robert Beck, MD†,§,
- Deeb N. Salem, MD, FACC†,
- N.A. Mark Estes, MD, FACC† and
- Stephen G. Pauker, MD, FACC1,†,‡
- ↵1Address for reprints: Stephen G. Pauker, MD, 171 Harrison Avenue, Boston, Massachusetts 02111.
This review illustrates the use of computer-based Markov models to estimate cost-effectiveness and prognosis in a complex problem in clinical cardiology.
Decision analysis and cost-effectiveness analysis were used to assess whether to implant a permanent cardiac pacemaker, treat with drugs, perform electrophysiologic studies or observe patients who have two clinical features—syncope and bifascicular block—that may or may not be causally related. Using a Markov process model, a computer program simulated the prognosis of five cohorts of such patients—one treated conservatively, one given empiric antiarrhythmic drug therapy, one receiving a pacemaker, one treated with empiric drugs and pacing and one tested with electrophysiologic studies. On the basis of data from published reports and expert opinion, quality-adjusted life expectancy was calculated by summing the average time a member of each cohort would survive with and without symptoms for each ini- tial treatment choice. The costs were estimated from 1985 hospital charges.
For patients with normal left ventricular function, electrophysiologic testing provides a benefit of 14 quality-adjusted months of life over observation, at an additional cost of $24,200. Empiric pacing would add 2.5 additional months, at a further cost of $14,300. In patients with poor left ventricular function, empiric drug therapy offers 1.5 additional quality-adjusted months over observation, at a cost of $6,900. Electrophysiologic testing provides a further 16.5 months at an additional cost of $16,900. These results hold when the relation between symptoms and arrhythmia is not firmly established. Varying the probabilities of underlying ventricular tachyarrhythmias, bradyarrhythmic conduction defects or noncardiac causes of syncope affects the costeffectiveness relative to the alternative treatments.
↵† From the Division of Clinical Decision Making, Department of Medicine, New England Medical Center, Tufts University School of Medicine, Boston, Massachusetts
↵‡ From the Division of Cardiology, Department of Medicine, New England Medical Center, Tufts University School of Medicine, Boston, Massachusetts
↵§ From the Division of Department of Pathology, Dartmouth-Hitchcock Medical Center, Hanover, New Hampshire.
* Parts I to IV of this Seminar appeared in the October and November 1986 and January and March 1987 issues of the Journal.
- Received February 10, 1986.
- Revision received June 2, 1986.
- Accepted June 20, 1986.
- American College of Cardiology Foundation