Pediatric and Congenital EPCost-effectiveness of in-home automated external defibrillators for children with cardiac conditions associated with risk of sudden cardiac death
Introduction
Current guidelines recommend that children considered to be at high risk for sudden cardiac death (SCD) (conventionally defined as >6% over 5 years) receive an implantable cardioverter-defibrillator (ICD) for prevention.1 However, for children at intermediate risk for SCD (4%–6% over 5 years), the morbidity associated with ICD placement is believed to outweigh the relatively lower risk of SCD, and ICD insertion is not currently recommended. Guidance on lifesaving interventions that are safe and effective for widespread use in this group are limited.1
If a cardiac arrest event occurs in the community, the time to deployment of an automated external defibrillator (AED) by a bystander or Emergency Medical Services (EMS) typically exceeds 5 minutes, which is associated with an increased risk of death.2 Having an AED at home makes earlier termination of life-threatening ventricular tachyarrhythmias possible, potentially averting adverse outcomes.3,4 Therefore, we sought to examine the cost-effectiveness of in-home AED in children in the United States at intermediate risk for SCD.2,5,6 Hypertrophic cardiomyopathy (HCM) was used as the proxy disease to explore this subject because it is the most common cause of SCD in school-age children.7
Section snippets
Methods
We created a Markov model using TreeAge Pro software (2019 version; TreeAge Software Inc, Williamstown, MA) to estimate the cost-effectiveness of providing in-home AED to all children at intermediate risk for SCD with HCM. We used a theoretical cohort of 1550 children in the United States, derived from the approximate number of 10-year-old children in the United States, the prevalence of HCM in the general population of 1 in 500, and the estimated proportion of children with HCM who are
Results
Using our baseline estimates, our model demonstrated that distributing home AEDs to children with intermediate risk of SCD and HCM is cost-effective (Table 1). In this theoretical cohort, in-home AED resulted in 31 fewer deaths from cardiac causes but 3 more cases of SNM due to an increased number of surviving individuals. The in-home AED strategy resulted in 319 additional QALYs but at a higher cost of $28 million over the lifetime of the cohort (Table 2). The ICER was $86,458, which is below
Discussion
Our data suggest that home AED distribution for children with intermediate risk of SCD and HCM is cost-effective, based on the standard of <$100,000 per QALY gained. However, the model was vulnerable to multiple inputs, thus highlighting the importance of clinical risk assessment and education on early use for families of this population. For our theoretical cohort of individuals at intermediate risk for SCD (4%–6% over 5 years), the intervention was cost-effective. However, as the risk of SCD
Conclusion
In-home AED seems to be cost-effective for pediatric patients at intermediate risk for SCD, and it should be considered when developing guidelines for clinical management of these children. However, the model’s vulnerability, specifically to annual risk of death and early defibrillation, make clinical risk assessment and family education paramount.
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Cited by (4)
The Case for Home AED in Children, Adolescents, and Young Adults Not Meeting Criteria for ICD
2022, JACC: Clinical ElectrophysiologyCitation Excerpt :Although it is hard to estimate the number of children who will need a home AED, some idea of the scope may be estimated by using hypertrophic cardiomyopathy as the index disease with risk of SCD. Haag et al48 estimated that approximately 19% of children aged <18 years are at intermediate risk for SCD. With an incidence of 1:500 in the population, a population of 73 million children aged <18 years in the United States,49 and assuming that the SCD risk group is predominantly those ≥10 years of age, this gives an estimated number of 7,308 children at intermediate risk.
A systematic literature review of economic evaluations and cost-of-illness studies of inherited cardiomyopathies
2023, Netherlands Heart Journal
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Dr Toffey’s present address is Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215. Dr Sargent’s present address is McGovern Medical School at UTHealth, 6431 Fannin St, Houston, TX 077030.