Effects of Improved Detection And Treatment of Atrial Fibrillation On Burden of Disease Caused By Stroke In Germany

OBJECTIVES: Atrial fibrillation (AF) is a major risk factor for stroke with a prevalence of 1-2% of the general population. Patients with non-valvular AF show a 4 to5 times higher risk of stroke. According to a German registry study, AF goes undetected in one third of affected patients. Even if correctly diagnosed, AF is not always treated with oral anti-coagulants (OAC) according to treatment guidelines. For Germany, the estimated proportion of patients actually treated with OAC among all eligible AF-patients ranges from 38% to 83%. We studied the effects of improved detection and treatment of AF with OAC on the burden of disease caused by stroke in Germany. METHODS: We performed a simulation study, applying the methodology of Generalized Cost-Effectiveness Analysis (Hutubessy et al. 2003). Using registry data of stroke incidence and outcomes (modified Rankin Scale), we estimated the disease-burden of stroke (DALY) under status-quo conditions of AF care (rates of AF-detection and treatments with OAC or platelet-aggregation inhibitors). Using study results on the effectiveness of AF-treatments, we estimated a counterfactual null-scenario (no AF-treatment at all) and calculated the resulting disease-burden. Finally, we simulated an optimization scenario and compared the respective gain of DALYs avoided. RESULTS: Comparison of the status-quo-scenario (67% detected; 50% treated with OAC) with the null-scenario showed that approx. 12.300 first time stroke incidents (64.100 DALYs) annually were prevented by AF-treatment. In the optimization scenario (80% detected;75% treated) an additional 9.400 first time stroke incidents (48.800 DALYs) annually were prevented, with one third of the effect caused by improved detection. CONCLUSIONS: Intervention studies have shown, that AF-detection in primary care can be improved. With vitamin K antagonists, factor Xa inhibitors and direct thrombin inhibitors several substances for OAC-therapy are available that allow for a higher treatment rate according to existing guidelines. Further analyses show that these improvements would be highly cost-effective.