Incidence of complete heart block and cost-effectiveness of pacemaker therapy in India

Complete Heart Block (CHB) is a cardiac disease associated with extremely low heart rates and if untreated, results in average longevity of only 2.5 years. Extrapolating the demographics of CHB in the United States to the global population, we estimated the global annual incidence of the disease in 2005 to be 430,000. European baseline data resulted in similar estimates. More than 80% of these patients live in developing countries and most do not receive treatment. In India and China alone, there were 140,000 new cases (50,000 in India) and less than 20% in each country received treatment. The only effective treatment for CHB is implantation of a cardiac pacemaker. The key reasons for low pacemaker implant rates are lack of reimbursement, poor awareness and inadequate diagnosis of CHB. An economic model was developed to evaluate incremental cost-effectiveness of pacing vs no-pacing for CHB and analyzed for India. This economic model can be used to compute cost-effectiveness for any geography. The survival data from Barlow et al (2000), which reviewed the results from 9 studies in 704 patients, was used for the model. The average total mortality in CHB patient without pacemakers was 50% at 2.5 years and 68% at 5 years. Assuming Rs.72,000 ($1750) cost for a single-chamber pacemaker and it's implant in India, 7 year device longevity and mean age of 55 years at implant, the cost effectiveness of pacing therapy was Rs.32,000 ($773)/life year saved. Sensitivity analysis for various ages at implant did not significantly alter cost- effectiveness. This cost-effectiveness figure is well within the WHO recommendation of a cost-effective therapy as one less than 3*GNI/capita (Rs.89, 000 or $2160/life year saved). Changes in reimbursement policy for treatment of CHB, leading to greater adoption of pacing, can significantly reduce the disease burden attributable to this lethal cardiac disease.