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A 56-year-old man was seen in cardiology clinic with exertional chest pain, most marked when walking uphill. He was a heavy smoker but had no other cardiovascular risk factors. His 12-lead ECG was normal, and a CT coronary angiogram (CTCA) was organised with a suspected diagnosis of angina.

ObjectiveResponders to cardiac resynchronisation therapy whose device has a defibrillator component and who do not receive a therapy in the lifetime of the first generator have a very low incidence of appropriate therapy after box change. We investigated the cost implications of using a risk stratification tool at the time of generator change resulting in these patients being reimplanted with a resynchronisation pacemaker.MethodsA decision tree was created using previously published data which had demonstrated an annualised appropriate defibrillator therapy risk of 2.33%. Costs were calculated at National Health Service (NHS) national tariff rates (2016–2017). EQ-5D utility values were applied to device reimplantations, admissions and mortality data, which were then used to estimate quality-adjusted life-years (QALYs) over 5 years.ResultsAt 5 years, the incremental cost of replacing a resynchronisation defibrillator device with a second resynchronisation defibrillator versus resynchronisation pacemaker was £5045 per patient. Incremental QALY gained was 0.0165 (defibrillator vs pacemaker), resulting in an incremental cost-effectiveness ratio (ICER) of £305 712 per QALYs gained. Probabilistic sensitivity analysis resulted in an ICER of £313 612 (defibrillator vs pacemaker). For reimplantation of all patients with a defibrillator rather than a pacemaker to yield an ICER of less than £30 000 per QALY gained (current NHS cut-off for approval of treatment), the annual arrhythmic event rate would need to be 9.3%. The budget impact of selective replacement was a saving of £2 133 985 per year.ConclusionsImplanting low-risk patients with a resynchronisation defibrillator with the same device at the time of generator change is not cost-effective by current NHS criteria. Further research is required to understand the impact of these findings on individual patients at the time of generator change.

Background The RACPC is a well-established “one-stop” service, with goal to identify patients with stable chest pain due to coronary artery disease (CAD) and quickly reassure those with non-cardiac pain. In March 2010, NICE published a new guideline, which advocates assessing likelihood of CAD based on age, gender, history and risk factors (RF). If estimated likelihood is >60%, invasive coronary angiography (ICA) is recommended as the first-line diagnostic investigation. If estimated likelihood is 30%–60%, functional imaging is recommended. If estimated likelihood is Methods 167 consecutive patients referred to RACPC between October 2009 and March 2010 were retrospectively assessed for likelihood of CAD according to the new NICE guideline. Choice of investigations and eventual outcome (confirmed CAD vs no evidence of CAD) were compared between subgroups defined by estimated likelihood of CAD. An economic analysis of cost of investigation per patient was undertaken using current Payment by Results national tariffs. Results Our patient population had a high prevalence of RF with 38.1% having a total of three or more RF. Consequently 23.2% of patients had an estimated likelihood of CAD of 60%. 7.2% of patients were lost to follow-up. 14.4% of patients were ultimately confirmed to have CAD on ICA, which correlated with pre-test estimated likelihood. 6% of patients with likelihood 60% were confirmed to have CAD. Average cost of investigation per patient was £528. A negative ETT resulted in average cost per patient of £347. An inconclusive ETT resulted in higher cost (£728) as did inability to exercise (£435) due to the need for further investigations. A positive ETT resulted in average cost of £1174 due to the high cost of ICA. Were the NICE guideline strictly applied to our patient population, average cost per patient would have been substantially higher at £838 (£362 per patient if likelihood 60%). Overall this corresponds to a 60% increase in cost. Conclusion The 2010 NICE guideline appears to significantly overestimate the true risk in our patient population. Were the guideline strictly applied, almost half of our patients would proceed to ICA as a first-line investigation, but many of them would be found to have unobstructed coronary arteries. As ICA is an expensive investigation, this would inevitably result in a significant increase in average cost per patient. Relatively few patients would be eligible for CTCA, which is an excellent non-invasive “rule-out” test for CAD and relatively inexpensive compared with other investigations.