Electrocardiographic screening for drug-induced long qt to reduce sudden cardiac death in Psychiatric patients: a cost-effectiveness analysis

Abstract

e8 Volume 37 Number 8S ElECTroCardiographiC SCrEENiNg for drug-iNduCEd loNg qT To rEduCE SuddEN CardiaC dEaTh iN pSyChiaTriC paTiENTS: a CoST-EffECTiVENESS aNalySiS Antoine Poncet; Baris Gencer; Marc Blondon; Marianne Gex-Fabry; Christophe Combescure; Dipen Shah; Peter J. Schwartz; Marie Besson; and Francois R. Girardin Department of Health and Community Medicine, University Hospitals and University of Geneva, rue Gabrielle-Perret-Gentil 4, 1205 Geneva, Switzerland; Department of Internal Medicine, University Hospitals and University of Geneva, rue GabriellePerret-Gentil 4, 1205 Geneva, Switzerland; Department of Psychiatry, University Hospitals and University of Geneva, 2 chemin du Petit-Bel-Air, 1225 Chene-Bourg, Switzerland; Center for Cardiac Arrhythmias of Genetic Origin, IRCCS Istituto Auxologico Italiano, Milano, Italy; Department of Anesthesiology, Intensive Care, and Clinical Pharmacology, University Hospitals and University of Geneva, rue GabriellePerret-Gentil 4, 1205 Geneva, Switzerland; and Medical Directorate, University Hospitals and University of Geneva, rue Gabrielle-Perret-Gentil 4, 1205 Geneva, Switzerland Background: Sudden cardiac death is a leading cause of mortality in psychiatric patients. Long QT (LQT) triggered by psychotropic medication is common and predisposes to torsades-de-pointes (TdP) and subsequent mortality. We estimated the cost-effectiveness of electrocardiographic screening to detect drug-induced LQT in psychiatric inpatients. Material and Methods: We built a decision analytic model based on a decision tree to evaluate the cost-effectiveness and utility of LQT screening from a health care perspective. LQT proportion parameters were derived from an in-hospital cross-sectional study. We performed experts’ elicitation to estimate the risk of TdP, given the extent of QT prolongation. A TdP reduction of 65% after LQT detection was based on positive drug dechallenge rate and through adequate treatment and electrolyte adjustments. The base-case model uncertainty was assessed with one-way and probabilistic sensitivity analyses. Finally, the TdP-related mortality and TdP avoidance parameters were varied in a 2-way sensitivity analysis to assess their effect on the incremental cost-effectiveness ratio (ICER). Results: In the base-case scenario, the numbers of patients needed to screen were 1128 and 2817 to avoid one TdP and one death, respectively. The ICER of systematic ECG screening was $8644 (95% CI, 3144–82,498) per QALY. The probability of cost-effectiveness was 96% at a willingness-to-pay of $50,000 for one QALY. In sensitivity analyses, results were sensitive to the case-fatality of TdP episodes and to the TdP reduction following the diagnosis of LQT. Conclusions: In psychiatric hospitals, performing systematic ECG screening at admission helps reduce the number of sudden cardiac deaths in a cost-effective fashion.