Cost-effectiveness of extracorporeal CPR for out-of-hospital cardiac arrest: a trial-based Markov model with a lifetime horizon

BACKGROUND: Extracorporeal cardiopulmonary resuscitation (ECPR) can restore circulation in refractory out-of-hospital cardiac arrest (OHCA). A trial-based analysis with a one-year horizon showed limited cost-effectiveness of this demanding procedure. However, arguably, long-term incremental health benefits may justify high initial incremental costs. We assessed the cost-effectiveness of ECPR compared to conventional cardiopulmonary resuscitation (CCPR) for OHCA with a lifetime horizon using trial-based data. METHODS: Healthcare and societal costs and Quality Adjusted Life Years (QALY), assessed using EQ-5D-5L, were simulated over a 20-year period following ECPR or CCPR for OHCA using a Markov model. Data from the per-protocol population of a multicenter randomized controlled trial comparing ECPR with CCPR were used as input parameters. The Incremental Cost-Effectiveness Ratio (ICER) was expressed as Euros per QALY. Probabilistic and deterministic sensitivity analyses were performed. RESULTS: We used data from 33 ECPR and 47 CCPR patients. Mean±SD costs after one year were €26.372 ± 28.237 versus €10.356 ±37.706 and survival was 15% vs. 9% in patients treated with ECPR versus CCPR. Over a lifetime horizon, mean incremental costs and QALYs of ECPR were €160.969 and 0.66, respectively, resulting in an ICER of €242.122/QALY. At a willingness-to-pay threshold of €80.000 per QALY gained, the probability of ECPR being cost-effective was 46%. The costs of non-survivors in both arms and the QALYs gained were the major drivers of the ICER. CONCLUSION: ECPR for refractory OHCA has a low probability of being cost-effective. To enhance cost-effectiveness, improving ECPR effectiveness and reducing hospital costs of ECPR non-survivors are mandatory.