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.

The purpose of the Handbook is to provide systematic overview of medical and health informatics for health care professionals and for students in medicine and health care, who will be the clinical professionals of the next millennium. Health care professionals will use computers to support patient care, assess the quality of care, and enhance decision making, management, planning, and medical research. Computer-based patient records and electronic communications will be the most visible developments in the years ahead. The Handbook has been written by a host of renowned international authorities in medical and health informatics. The editors took much care that the Handbook would not be merely a collection of separate chapters, but rather would offer a consistent and structured overview.

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.