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Objectives: The purpose of this study was to determine the cost-effectiveness of physiologic pacemakers., Background: The Canadian Trial of Physiologic Pacing (CTOPP) was a large randomized trial that evaluated the efficacy of physiologic pacing compared with ventricular pacing. CTOPP also included a prospective cost-effectiveness substudy., Methods: Resource usage and costs were collected from a subset of 472 patients (of 1,094) who received a physiologic pacemaker and 586 (of 1,474) who received a ventricular pacemaker. Costs included initial pacemaker implantation and all health care follow-up costs over a follow-up of 5.2 years. Costs are reported in 2004 Canadian dollars (1 Canadian dollar = 0.76 US dollars), with adjustments for censoring. Incremental cost-effectiveness was estimated as the ratio of the difference (treatment-control) in mean cost to the difference in life expectancy (mean survival), with costs and effects discounted at 3% per year., Results: Over a mean follow-up of 3.1 years, physiologic pacing was associated with a gain of 0.01 life-years. This benefit increases to 0.25 life-years in the subgroup of patients with an intrinsic (unpaced) heart rate < or =60 bpm. Physiologic pacing was more expensive than ventricular (16,833 Canadian dollars vs 13,857 US dollars), largely because of the increased cost of dual-chamber devices. Among all substudy patients, the incremental cost-effectiveness of physiologic pacing is 297,600 Canadian dollars per life-year gained; however, this value falls to 16,343 Canadian dollars in patients with an intrinsic heart rate >60., Conclusions: In the short term, a strategy of routine implantation of physiologic pacemakers is not cost-effective by currently accepted standards. The selective use of these devices in patients likely to be pacemaker dependent appears to be cost-effective. Further studies with longer follow-up and which consider the benefit of reducing nonfatal cardiac events would be valuable.

Pacemaker reimplantation in the same patient is common, and pacemaker transplantation or reuse in a second patient has been reported. No report prospectively compares the long term costs, the impact of reuse on the number of pacemakers implanted, the pacemaker related complications, the types of patients selected and the patient survival of those who receive new versus a refurbished pacemaker. The authors implanted 70 pacemakers of which 75% (52) were new and 25% (18) were refurbished. The refurbished pacemakers were implanted in older patients (P less than 0.02), with a mean +/- SD of 77 +/- 8 versus 69 +/- 13 years of age. During a follow-up period of 36 months, the rate of pacemaker related complications was the same in both groups, with no unusual or unexpected problems arising in the refurbished group. There were 12 (23%) complications in the new pacemaker group and four (22%) complications in the refurbished pacemaker group. There were no major pacemaker related complications, no pacemaker battery depletions and no pacemaker related deaths. The refurbished pacemakers saved $33,000. After three years the cumulative probability of survival in the new group tended to be higher (P = 0.08) with a mean (SE) of 0.62 (0.12) versus 0.44 (0.15). New and refurbished pacemakers are similar with respect to pacemaker related survival and complications. Refurbished pacemakers effect a major reduction in pacemaker costs while maintaining health care standards.