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* Calculation assumes 0.5 additional life-year saved for year in which life was saved. ID = implantable cardioverter defibrillator.

* Calculation assumes 0.5 additional life-year saved for year in which life was saved. ID = implantable cardioverter defibrillator.

of sudden death, and an annual 5% risk of death from other causes (i.e., patients are similar to those in Population 2). Patients in Group B (Table 4) also have a 10% yearly risk of sudden death, but their risk of death from other causes is much higher: 33% yearly (similar to Population 3). During the 5 yr after implantation, the defibrillator would add a net of 1.03 life-years per patient in Group A, but only 0.31 life-years per patient in Group B. At a cost of $30,000 per implantation, the cost per life-year saved would be approx $29,000 for Group A and $98,000 for Group B.

Note that the data used to calculate these values are epidemiological data, similar to that available from the Framingham study. With such data in hand, we only need to decide how much we are willing to spend to prolong a patient's life by 1 yr (the going rate, unofficially, is $50,000 per life-year saved), and plug the numbers into a spreadsheet. If a patient's statistical risk of sudden death is high enough, and the risk of death from other causes low enough, the cost will fall under the threshold value and we would implant a defibrillator. If not, patients would receive alternative therapy.

Such a methodology admittedly may sound radical. It does, however, bring a fundamental fact about how we use the defibrillator into the light of day. Namely, our use of the ICD meets the "but for" test for rationing: Since ICDs are unsurpassed at preventing sudden arrhythmic death, then but for the expense, we would implant these devices in everybody who has a substantially increased risk for sudden death.

This suggested methodology does not introduce rationing to our use of the defibrilla-

tor—it simply makes the rationing we are doing more open, and arguably more fair. It also would be relatively quick and simple to implement, and would save us the time and expense of conducting a score of randomized trials, one for each identifiable subset of potentially eligible patients, to determine who gets the defibrillator.

Given the continued high cost and complexity of the ICD however, no matter how we ultimately decide to expand its indications, making an appreciable impact in the worldwide incidence of sudden death will probably never be possible with this device. Such an impact will almost certainly require a breakthrough outside the realm of implantable antitachycardia devices.

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