Health Care Systems: How to Resolve the Dilemma Between Clinical Needs and Limited Resources?

Abstract

Are the appropriate indications for ICDs (based on clinical evidence) limited by health care system resources? An overview of the number of ICD (including CRT-D) implants and their costs in USA, Europe, and Italy in 2003 and 2004 is provided in Tables 1 and 2. ICD therapy accounts for only a small percentage of the total expenditure of health care systems, and there are large numbers of appropriate patients who do not receive ICDs, although the annual incidence of implants is increasing. The number of patients receiving ICDs (or CRT-Ds) has increased ten-fold over the last 10 years in Europe and in the USA [1]. In Italy, the implantation rate in 2003 increased by 45% compared to the rate in 2002 and by a further 23% in 2004 compared to 2003 (Tables 3, 4). Nevertheless, the total expenditure for ICDs (which includes device costs plus implantation and follow-up) still remains a modest percentage of total health expenditures. Furthermore, the number of patients who could benefit from this therapy is miniscule compared to the general population. For example, in Europe, in 2004, about 40 000 patients received ICDs, and the associated in-patient expenditures, amounted to € 0.6 billion, accounting for 0.2% of total in-patient expenditures. Similarly in Italy, in 2004, about 8000 patients received ICDs/CRT-Ds, and the in-patient expenditures for these were € 0.13 billion, accounting for 0.3% of total in-patient expenditures. Figure 1 compares the expenditure for ICDs with those of other accepted therapies in the USA in 2000. The cost of ICD was four-fold lower than that for PTCA or CABG and 15-times lower than that for antibiotics.