Cost-effectiveness of combined catheter ablation and left atrial appendage closure for symptomatic atrial fibrillation in patients with high stroke and bleeding risk
Combined catheter ablation (CA) and left atrial appendage closure (LAAC) have been proposed for management of symptomatic atrial fibrillation (AF) in patients with high stroke and bleeding risk. We assessed the cost-effectiveness of combined CA and LAAC compared with CA and standard oral anticoagula...
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| Veröffentlicht in: | The American heart journal 2021-01, Vol.231, p.110-120 |
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| creator | Kawakami, Hiroshi Nolan, Mark T. Phillips, Karen Scuffham, Paul A. Marwick, Thomas H. |
| description | Combined catheter ablation (CA) and left atrial appendage closure (LAAC) have been proposed for management of symptomatic atrial fibrillation (AF) in patients with high stroke and bleeding risk. We assessed the cost-effectiveness of combined CA and LAAC compared with CA and standard oral anticoagulation (OAC) in symptomatic AF.
A Markov model was developed to assess total costs, quality-adjusted life-years (QALYs), and the incremental cost-effectiveness ratio among 2 post-CA strategies: (1) standard OAC and (2) LAAC (combined CA and LAAC procedure). The base-case used a 10-year time horizon and consisted of a hypothetical cohort of patients aged 65 years with symptomatic AF, with high thrombotic (CHA2DS2-VASc = 3) and bleeding risk (HAS-BLED = 3), and planned for AF ablation. Values for transition probabilities, utilities, and costs were derived from the literature. Costs were converted to 2020 US dollars. Half-cycle correction was applied, and costs and QALYs were discounted at 3% annually. Sensitivity analyses were performed for significant variables and scenario analyses for higher embolic risk.
In the base-case cohort of 10,000 patients followed for 10 years, total costs for the LAAC strategy were $29,027 and for OAC strategy were $27,896. The LAAC strategy was associated with 122 fewer disabling strokes and 203 fewer intracranial hemorrhages per 10,000 patients compared with the OAC strategy. The LAAC strategy had an incremental cost-effectiveness ratio of $11,072/QALY. In sensitivity analyses, although cost-effectiveness was highly dependent on the risk of intracranial hemorrhage in the LAAC strategy and the cost of the combined procedure, LAAC was superior to OAC under the most circumstances. Scenario analyses demonstrated that the combined procedure was more cost-effective in patients with higher stroke risk.
In symptomatic AF patients with high stroke and bleeding risk who are planned for CA, the combined CA and LAAC procedure may be a cost-effective therapeutic option and be more beneficial to patients with CHA2DS2-VASc risk score ≥3. |
| doi_str_mv | 10.1016/j.ahj.2020.08.008 |
| format | Article |
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A Markov model was developed to assess total costs, quality-adjusted life-years (QALYs), and the incremental cost-effectiveness ratio among 2 post-CA strategies: (1) standard OAC and (2) LAAC (combined CA and LAAC procedure). The base-case used a 10-year time horizon and consisted of a hypothetical cohort of patients aged 65 years with symptomatic AF, with high thrombotic (CHA2DS2-VASc = 3) and bleeding risk (HAS-BLED = 3), and planned for AF ablation. Values for transition probabilities, utilities, and costs were derived from the literature. Costs were converted to 2020 US dollars. Half-cycle correction was applied, and costs and QALYs were discounted at 3% annually. Sensitivity analyses were performed for significant variables and scenario analyses for higher embolic risk.
In the base-case cohort of 10,000 patients followed for 10 years, total costs for the LAAC strategy were $29,027 and for OAC strategy were $27,896. The LAAC strategy was associated with 122 fewer disabling strokes and 203 fewer intracranial hemorrhages per 10,000 patients compared with the OAC strategy. The LAAC strategy had an incremental cost-effectiveness ratio of $11,072/QALY. In sensitivity analyses, although cost-effectiveness was highly dependent on the risk of intracranial hemorrhage in the LAAC strategy and the cost of the combined procedure, LAAC was superior to OAC under the most circumstances. Scenario analyses demonstrated that the combined procedure was more cost-effective in patients with higher stroke risk.
In symptomatic AF patients with high stroke and bleeding risk who are planned for CA, the combined CA and LAAC procedure may be a cost-effective therapeutic option and be more beneficial to patients with CHA2DS2-VASc risk score ≥3.</description><identifier>ISSN: 0002-8703</identifier><identifier>EISSN: 1097-6744</identifier><identifier>EISSN: 1097-5330</identifier><identifier>DOI: 10.1016/j.ahj.2020.08.008</identifier><identifier>PMID: 32822655</identifier><language>eng</language><publisher>NEW YORK: Elsevier Inc</publisher><subject>Ablation ; Aged ; Anticoagulants ; Anticoagulants - therapeutic use ; Atrial Appendage - surgery ; Atrial Fibrillation - complications ; Atrial Fibrillation - surgery ; Bleeding ; Cardiac & Cardiovascular Systems ; Cardiac arrhythmia ; Cardiovascular System & Cardiology ; Catheter Ablation - economics ; Catheters ; Combined Modality Therapy - economics ; Combined Modality Therapy - methods ; Cost analysis ; Cost assessments ; Cost-Benefit Analysis ; Economic analysis ; Fibrillation ; Health risks ; Hemorrhage ; Hemorrhage - etiology ; Humans ; Intubation ; Life Sciences & Biomedicine ; Markov Chains ; Medical instruments ; Mortality ; Patients ; Probability ; Quality assessment ; Quality-Adjusted Life Years ; Radiofrequency ablation ; Science & Technology ; Sensitivity analysis ; Strategy ; Stroke ; Stroke - etiology ; Transition probabilities ; Utilities</subject><ispartof>The American heart journal, 2021-01, Vol.231, p.110-120</ispartof><rights>2020 Elsevier Inc.</rights><rights>Copyright © 2020 Elsevier Inc. All rights reserved.</rights><rights>2020. Elsevier Inc.</rights><lds50>peer_reviewed</lds50><woscitedreferencessubscribed>true</woscitedreferencessubscribed><woscitedreferencescount>9</woscitedreferencescount><woscitedreferencesoriginalsourcerecordid>wos000604578300015</woscitedreferencesoriginalsourcerecordid><citedby>FETCH-LOGICAL-c381t-16b90de7db8b805278e1774c50108e131cf194f1142ff51c9127edd8cfeb3a9a3</citedby><cites>FETCH-LOGICAL-c381t-16b90de7db8b805278e1774c50108e131cf194f1142ff51c9127edd8cfeb3a9a3</cites><orcidid>0000-0001-5931-642X ; 0000-0001-9065-0899</orcidid></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktohtml>$$Uhttps://www.proquest.com/docview/2470889015?pq-origsite=primo$$EHTML$$P50$$Gproquest$$H</linktohtml><link.rule.ids>315,781,785,3551,27928,27929,39262,45999,64389,64391,64393,72473</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/32822655$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Kawakami, Hiroshi</creatorcontrib><creatorcontrib>Nolan, Mark T.</creatorcontrib><creatorcontrib>Phillips, Karen</creatorcontrib><creatorcontrib>Scuffham, Paul A.</creatorcontrib><creatorcontrib>Marwick, Thomas H.</creatorcontrib><title>Cost-effectiveness of combined catheter ablation and left atrial appendage closure for symptomatic atrial fibrillation in patients with high stroke and bleeding risk</title><title>The American heart journal</title><addtitle>AM HEART J</addtitle><addtitle>Am Heart J</addtitle><description>Combined catheter ablation (CA) and left atrial appendage closure (LAAC) have been proposed for management of symptomatic atrial fibrillation (AF) in patients with high stroke and bleeding risk. We assessed the cost-effectiveness of combined CA and LAAC compared with CA and standard oral anticoagulation (OAC) in symptomatic AF.
A Markov model was developed to assess total costs, quality-adjusted life-years (QALYs), and the incremental cost-effectiveness ratio among 2 post-CA strategies: (1) standard OAC and (2) LAAC (combined CA and LAAC procedure). The base-case used a 10-year time horizon and consisted of a hypothetical cohort of patients aged 65 years with symptomatic AF, with high thrombotic (CHA2DS2-VASc = 3) and bleeding risk (HAS-BLED = 3), and planned for AF ablation. Values for transition probabilities, utilities, and costs were derived from the literature. Costs were converted to 2020 US dollars. Half-cycle correction was applied, and costs and QALYs were discounted at 3% annually. Sensitivity analyses were performed for significant variables and scenario analyses for higher embolic risk.
In the base-case cohort of 10,000 patients followed for 10 years, total costs for the LAAC strategy were $29,027 and for OAC strategy were $27,896. The LAAC strategy was associated with 122 fewer disabling strokes and 203 fewer intracranial hemorrhages per 10,000 patients compared with the OAC strategy. The LAAC strategy had an incremental cost-effectiveness ratio of $11,072/QALY. In sensitivity analyses, although cost-effectiveness was highly dependent on the risk of intracranial hemorrhage in the LAAC strategy and the cost of the combined procedure, LAAC was superior to OAC under the most circumstances. Scenario analyses demonstrated that the combined procedure was more cost-effective in patients with higher stroke risk.
In symptomatic AF patients with high stroke and bleeding risk who are planned for CA, the combined CA and LAAC procedure may be a cost-effective therapeutic option and be more beneficial to patients with CHA2DS2-VASc risk score ≥3.</description><subject>Ablation</subject><subject>Aged</subject><subject>Anticoagulants</subject><subject>Anticoagulants - therapeutic use</subject><subject>Atrial Appendage - surgery</subject><subject>Atrial Fibrillation - complications</subject><subject>Atrial Fibrillation - surgery</subject><subject>Bleeding</subject><subject>Cardiac & Cardiovascular Systems</subject><subject>Cardiac arrhythmia</subject><subject>Cardiovascular System & Cardiology</subject><subject>Catheter Ablation - economics</subject><subject>Catheters</subject><subject>Combined Modality Therapy - economics</subject><subject>Combined Modality Therapy - methods</subject><subject>Cost analysis</subject><subject>Cost assessments</subject><subject>Cost-Benefit Analysis</subject><subject>Economic analysis</subject><subject>Fibrillation</subject><subject>Health risks</subject><subject>Hemorrhage</subject><subject>Hemorrhage - etiology</subject><subject>Humans</subject><subject>Intubation</subject><subject>Life Sciences & Biomedicine</subject><subject>Markov Chains</subject><subject>Medical instruments</subject><subject>Mortality</subject><subject>Patients</subject><subject>Probability</subject><subject>Quality assessment</subject><subject>Quality-Adjusted Life Years</subject><subject>Radiofrequency ablation</subject><subject>Science & Technology</subject><subject>Sensitivity analysis</subject><subject>Strategy</subject><subject>Stroke</subject><subject>Stroke - etiology</subject><subject>Transition probabilities</subject><subject>Utilities</subject><issn>0002-8703</issn><issn>1097-6744</issn><issn>1097-5330</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2021</creationdate><recordtype>article</recordtype><sourceid>HGBXW</sourceid><sourceid>EIF</sourceid><sourceid>8G5</sourceid><sourceid>ABUWG</sourceid><sourceid>AFKRA</sourceid><sourceid>AZQEC</sourceid><sourceid>BENPR</sourceid><sourceid>CCPQU</sourceid><sourceid>DWQXO</sourceid><sourceid>GNUQQ</sourceid><sourceid>GUQSH</sourceid><sourceid>M2O</sourceid><recordid>eNqNks1u1DAUhSMEokPhAdggS2yQUIZr58eOWFWj8iNVYgNry3GuZzxN7GA7rfpAvGc9nWkXLBArH0vfub73HhfFWwprCrT9tF-r3X7NgMEaxBpAPCtWFDpetryunxcrAGCl4FCdFa9i3Odry0T7sjirmGCsbZpV8WfjYyrRGNTJ3qDDGIk3RPuptw4HolXaYcJAVD-qZL0jyg1kRJOISsGqkah5RjeoLRI9-rgEJMYHEu-mOfkpW_QjaGwf7HiqYh2Zs0KXIrm1aUd2drsjMQV_jQ9P9CPiYN2WBBuvXxcvjBojvjmd58WvL5c_N9_Kqx9fv28urkpdCZpK2vYdDMiHXvQCGsYFUs5r3QCFLCuqDe1qQ2nNjGmo7ijjOAxCG-wr1anqvPhwrDsH_3vBmORko8bctEO_RMnqqq2h4oJl9P1f6N4vweXuMsVBiA5okyl6pHTwMQY0cg52UuFOUpCHDOVe5gzlIUMJQuYMs-fdqfLSTzg8OR5Dy4A4ArfYexN13qLGJ-yQMtQNF1VWtNnY9LDxjV9cytaP_2_N9OcjjXnnNxaDPDkGG_J_kYO3_5jjHk3a0Dw</recordid><startdate>202101</startdate><enddate>202101</enddate><creator>Kawakami, Hiroshi</creator><creator>Nolan, Mark T.</creator><creator>Phillips, Karen</creator><creator>Scuffham, Paul A.</creator><creator>Marwick, Thomas H.</creator><general>Elsevier Inc</general><general>Elsevier</general><general>Elsevier Limited</general><scope>BLEPL</scope><scope>DTL</scope><scope>HGBXW</scope><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>3V.</scope><scope>7QO</scope><scope>7RV</scope><scope>7TS</scope><scope>7X7</scope><scope>7XB</scope><scope>88C</scope><scope>88E</scope><scope>8AO</scope><scope>8C1</scope><scope>8FD</scope><scope>8FI</scope><scope>8FJ</scope><scope>8FK</scope><scope>8G5</scope><scope>ABUWG</scope><scope>AFKRA</scope><scope>AN0</scope><scope>AZQEC</scope><scope>BENPR</scope><scope>CCPQU</scope><scope>DWQXO</scope><scope>FR3</scope><scope>FYUFA</scope><scope>GHDGH</scope><scope>GNUQQ</scope><scope>GUQSH</scope><scope>K9.</scope><scope>KB0</scope><scope>M0S</scope><scope>M0T</scope><scope>M1P</scope><scope>M2O</scope><scope>MBDVC</scope><scope>NAPCQ</scope><scope>P64</scope><scope>PQEST</scope><scope>PQQKQ</scope><scope>PQUKI</scope><scope>PRINS</scope><scope>Q9U</scope><scope>7X8</scope><orcidid>https://orcid.org/0000-0001-5931-642X</orcidid><orcidid>https://orcid.org/0000-0001-9065-0899</orcidid></search><sort><creationdate>202101</creationdate><title>Cost-effectiveness of combined catheter ablation and left atrial appendage closure for symptomatic atrial fibrillation in patients with high stroke and bleeding risk</title><author>Kawakami, Hiroshi ; Nolan, Mark T. ; Phillips, Karen ; Scuffham, Paul A. ; Marwick, Thomas H.</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c381t-16b90de7db8b805278e1774c50108e131cf194f1142ff51c9127edd8cfeb3a9a3</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2021</creationdate><topic>Ablation</topic><topic>Aged</topic><topic>Anticoagulants</topic><topic>Anticoagulants - therapeutic use</topic><topic>Atrial Appendage - surgery</topic><topic>Atrial Fibrillation - complications</topic><topic>Atrial Fibrillation - surgery</topic><topic>Bleeding</topic><topic>Cardiac & Cardiovascular Systems</topic><topic>Cardiac arrhythmia</topic><topic>Cardiovascular System & Cardiology</topic><topic>Catheter Ablation - economics</topic><topic>Catheters</topic><topic>Combined Modality Therapy - economics</topic><topic>Combined Modality Therapy - methods</topic><topic>Cost analysis</topic><topic>Cost assessments</topic><topic>Cost-Benefit Analysis</topic><topic>Economic analysis</topic><topic>Fibrillation</topic><topic>Health risks</topic><topic>Hemorrhage</topic><topic>Hemorrhage - etiology</topic><topic>Humans</topic><topic>Intubation</topic><topic>Life Sciences & Biomedicine</topic><topic>Markov Chains</topic><topic>Medical instruments</topic><topic>Mortality</topic><topic>Patients</topic><topic>Probability</topic><topic>Quality assessment</topic><topic>Quality-Adjusted Life Years</topic><topic>Radiofrequency ablation</topic><topic>Science & Technology</topic><topic>Sensitivity analysis</topic><topic>Strategy</topic><topic>Stroke</topic><topic>Stroke - etiology</topic><topic>Transition probabilities</topic><topic>Utilities</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Kawakami, Hiroshi</creatorcontrib><creatorcontrib>Nolan, Mark T.</creatorcontrib><creatorcontrib>Phillips, Karen</creatorcontrib><creatorcontrib>Scuffham, Paul A.</creatorcontrib><creatorcontrib>Marwick, Thomas H.</creatorcontrib><collection>Web of Science Core Collection</collection><collection>Science Citation Index Expanded</collection><collection>Web of Science - Science Citation Index Expanded - 2021</collection><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>ProQuest Central (Corporate)</collection><collection>Biotechnology Research Abstracts</collection><collection>Nursing & Allied Health Database</collection><collection>Physical Education Index</collection><collection>Health & Medical Collection</collection><collection>ProQuest Central (purchase pre-March 2016)</collection><collection>Healthcare Administration Database (Alumni)</collection><collection>Medical Database (Alumni Edition)</collection><collection>ProQuest Pharma Collection</collection><collection>Public Health Database</collection><collection>Technology Research Database</collection><collection>Hospital Premium Collection</collection><collection>Hospital Premium Collection (Alumni Edition)</collection><collection>ProQuest Central (Alumni) (purchase pre-March 2016)</collection><collection>Research Library (Alumni Edition)</collection><collection>ProQuest Central (Alumni Edition)</collection><collection>ProQuest Central UK/Ireland</collection><collection>British Nursing Database</collection><collection>ProQuest Central Essentials</collection><collection>ProQuest Central</collection><collection>ProQuest One Community College</collection><collection>ProQuest Central Korea</collection><collection>Engineering Research Database</collection><collection>Health Research Premium Collection</collection><collection>Health Research Premium Collection (Alumni)</collection><collection>ProQuest Central Student</collection><collection>Research Library Prep</collection><collection>ProQuest Health & Medical Complete (Alumni)</collection><collection>Nursing & Allied Health Database (Alumni Edition)</collection><collection>Health & Medical Collection (Alumni Edition)</collection><collection>Healthcare Administration Database</collection><collection>Medical Database</collection><collection>Research Library</collection><collection>Research Library (Corporate)</collection><collection>Nursing & Allied Health Premium</collection><collection>Biotechnology and BioEngineering Abstracts</collection><collection>ProQuest One Academic Eastern Edition (DO NOT USE)</collection><collection>ProQuest One Academic</collection><collection>ProQuest One Academic UKI Edition</collection><collection>ProQuest Central China</collection><collection>ProQuest Central Basic</collection><collection>MEDLINE - Academic</collection><jtitle>The American heart journal</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Kawakami, Hiroshi</au><au>Nolan, Mark T.</au><au>Phillips, Karen</au><au>Scuffham, Paul A.</au><au>Marwick, Thomas H.</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Cost-effectiveness of combined catheter ablation and left atrial appendage closure for symptomatic atrial fibrillation in patients with high stroke and bleeding risk</atitle><jtitle>The American heart journal</jtitle><stitle>AM HEART J</stitle><addtitle>Am Heart J</addtitle><date>2021-01</date><risdate>2021</risdate><volume>231</volume><spage>110</spage><epage>120</epage><pages>110-120</pages><issn>0002-8703</issn><eissn>1097-6744</eissn><eissn>1097-5330</eissn><abstract>Combined catheter ablation (CA) and left atrial appendage closure (LAAC) have been proposed for management of symptomatic atrial fibrillation (AF) in patients with high stroke and bleeding risk. We assessed the cost-effectiveness of combined CA and LAAC compared with CA and standard oral anticoagulation (OAC) in symptomatic AF.
A Markov model was developed to assess total costs, quality-adjusted life-years (QALYs), and the incremental cost-effectiveness ratio among 2 post-CA strategies: (1) standard OAC and (2) LAAC (combined CA and LAAC procedure). The base-case used a 10-year time horizon and consisted of a hypothetical cohort of patients aged 65 years with symptomatic AF, with high thrombotic (CHA2DS2-VASc = 3) and bleeding risk (HAS-BLED = 3), and planned for AF ablation. Values for transition probabilities, utilities, and costs were derived from the literature. Costs were converted to 2020 US dollars. Half-cycle correction was applied, and costs and QALYs were discounted at 3% annually. Sensitivity analyses were performed for significant variables and scenario analyses for higher embolic risk.
In the base-case cohort of 10,000 patients followed for 10 years, total costs for the LAAC strategy were $29,027 and for OAC strategy were $27,896. The LAAC strategy was associated with 122 fewer disabling strokes and 203 fewer intracranial hemorrhages per 10,000 patients compared with the OAC strategy. The LAAC strategy had an incremental cost-effectiveness ratio of $11,072/QALY. In sensitivity analyses, although cost-effectiveness was highly dependent on the risk of intracranial hemorrhage in the LAAC strategy and the cost of the combined procedure, LAAC was superior to OAC under the most circumstances. Scenario analyses demonstrated that the combined procedure was more cost-effective in patients with higher stroke risk.
In symptomatic AF patients with high stroke and bleeding risk who are planned for CA, the combined CA and LAAC procedure may be a cost-effective therapeutic option and be more beneficial to patients with CHA2DS2-VASc risk score ≥3.</abstract><cop>NEW YORK</cop><pub>Elsevier Inc</pub><pmid>32822655</pmid><doi>10.1016/j.ahj.2020.08.008</doi><tpages>11</tpages><orcidid>https://orcid.org/0000-0001-5931-642X</orcidid><orcidid>https://orcid.org/0000-0001-9065-0899</orcidid></addata></record> |
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| subjects | Ablation Aged Anticoagulants Anticoagulants - therapeutic use Atrial Appendage - surgery Atrial Fibrillation - complications Atrial Fibrillation - surgery Bleeding Cardiac & Cardiovascular Systems Cardiac arrhythmia Cardiovascular System & Cardiology Catheter Ablation - economics Catheters Combined Modality Therapy - economics Combined Modality Therapy - methods Cost analysis Cost assessments Cost-Benefit Analysis Economic analysis Fibrillation Health risks Hemorrhage Hemorrhage - etiology Humans Intubation Life Sciences & Biomedicine Markov Chains Medical instruments Mortality Patients Probability Quality assessment Quality-Adjusted Life Years Radiofrequency ablation Science & Technology Sensitivity analysis Strategy Stroke Stroke - etiology Transition probabilities Utilities |
| title | Cost-effectiveness of combined catheter ablation and left atrial appendage closure for symptomatic atrial fibrillation in patients with high stroke and bleeding risk |
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