Implantable cardioverter defibrillators (ICDs) are remarkably effective in terminating ventricular arrhythmias, but they are expensive and the extent to which they extend life is unknown. The marginal cost-effectiveness of ICDs relative to amiodarone has not been clearly established.

Objective: To compare the cost-effectiveness of a third-generation implantable ICD with that of empirical amiodarone treatment for preventing sudden cardiac death in patients at high or intermediate risk.

Results: For the base-case analysis, it was assumed that treatment with an ICD would reduce the total mortality rate by 20% to 40% at 1 year compared with amiodarone and that the ICD generator would be replaced every 4 years. In high-risk patients, if an ICD reduces total mortality by 20%, patients who receive an ICD live for 4.18 quality-adjusted life-years and have a lifetime expenditure of $88 400. Patients receiving amiodarone live for 3.68 quality-adjusted life-years and have a lifetime expenditure of $51 000. Marginal cost-effectiveness of an ICD relative to amiodarone is $74 400 per quality-adjusted life-year saved. If an ICD reduces mortality by 40%, the cost-effectiveness of ICD use is $37 300 per quality-adjusted life-year saved. Both choice of therapy (an ICD or amiodarone) and the cost-effectiveness ratio are sensitive to assumptions about quality of life.

Conclusions: Use of an ICD will cost more than $50,000 per quality-adjusted life-year gained unless it reduces all-cause mortality by 30% or more relative to amiodarone. Current evidence does not definitively support or exclude a benefit of this magnitude, but ongoing randomized trials have sufficient statistical power to do so.

Pulmonary rehabilitation programmes improve the health of patients disabled by lung disease but their cost eVectiveness is unproved. This cost/utility analysis was undertaken in conjunction with a randomised controlled clinical trial of pulmonary rehabilitation versus standard care.

Objective: To determine the hospital cost of caring for newborn infants with congenital syphilis.

Study Population: All live-born singleton neonates with birth weight greater than 500 gm at an inner-city municipal hospital in New York City in 1989.

Methods: We compared the characteristics of 114 infants with case-compatible congenital syphilis with those of 2906 infants without syphilis. Cost estimates were based on New York State newborn diagnosis-related groups (DRG) reimbursements adjusted for length of stay, birth weight, preterm delivery, and selected maternal risk factors, including infection with the human immunodeficiency virus, cocaine use during pregnancy, and history of injected drug use.

Results: For infants with congenital syphilis, the unadjusted mean cost ($11,031) and the median cost ($4961) were more than three times larger than those for infants without syphilis (p 0.01). After adjustment, congenital syphilis was associated with an additional length of hospitalization of 7 1/2 days and an additional cost of $4690 (both p 0.01) above mean study population values (7.13 days, $3473).

Conclusions: Based on the number of reported cases (1991 to 1994), the average annual national cost of treating infants with congenital syphilis is approximately $18.4 million (1995 dollars). This estimate provides a benchmark to assess the cost-effectiveness of strategies to prevent, diagnose, and treat the disease.

Evidence-Based Medicine 1996 Jul-Aug;1:158. Comment on Javitt JC, Aiello LP. Cost-effectiveness of detecting and treating diabetic retinopathy