Jacqueline Saw1, Maria C Bennell2, Sheldon M Singh2, Harindra C Wijeysundera3. 1. Division of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada. Electronic address: jsaw@mail.ubc.ca. 2. Schulich Heart Center, Division of Cardiology, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada. 3. Schulich Heart Center, Division of Cardiology, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada; Institute for Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, Ontario, Canada.
Abstract
BACKGROUND: Percutaneous left atrial appendage closure (LAAC) is increasingly performed as an alternative to oral anticoagulation (OAC) in patients with nonvalvular atrial fibrillation (AF). We sought to evaluate the cost-effectiveness of treating OAC contraindicated patients with LAAC compared with aspirin alone. METHODS: A probabilistic patient-level Markov microsimulation model with a lifetime horizon was performed to assess the discounted lifetime costs, quality-adjusted life years, and incremental cost-effectiveness ratio of LAAC compared with aspirin for patients with AF with contraindications to OAC. Baseline characteristics were based on a published multicenter Canadian LAAC experience. Clinical events included stroke, bleeding, myocardial infarction, and procedure-related complications. Event rates for stroke and bleeding were based on the CHA2DS2-VASc and HAS-BLED scores. The relative efficacies of LAAC and aspirin, as well as utility scores, were obtained from the published literature. Canadian procedural and long-term costs were obtained from the Ontario Case Costing Initiative and the Ontario Ministry of Health and Long Term Care. RESULTS: Aspirin was less effective than LAAC (4.25 ± 0.53 vs 4.66 ± 0.34 quality-adjusted life years, respectively). The average discounted lifetime cost was CAD$30,748 ± 11,600 for LAAC and $38,974 ± 18,783 for aspirin. Thus, LAAC was dominant, being more effective and less expensive. Our results were robust with a relatively low degree of uncertainty, as LAAC was the preferred option in more than 90% of simulations at a willingness-to-pay threshold of $50,000. CONCLUSIONS: LAAC is a novel stroke preventative therapy for nonvalvular AF and is a cost-effective alternative to aspirin in patients with contraindications to OAC.
BACKGROUND: Percutaneous left atrial appendage closure (LAAC) is increasingly performed as an alternative to oral anticoagulation (OAC) in patients with nonvalvular atrial fibrillation (AF). We sought to evaluate the cost-effectiveness of treating OAC contraindicated patients with LAAC compared with aspirin alone. METHODS: A probabilistic patient-level Markov microsimulation model with a lifetime horizon was performed to assess the discounted lifetime costs, quality-adjusted life years, and incremental cost-effectiveness ratio of LAAC compared with aspirin for patients with AF with contraindications to OAC. Baseline characteristics were based on a published multicenter Canadian LAAC experience. Clinical events included stroke, bleeding, myocardial infarction, and procedure-related complications. Event rates for stroke and bleeding were based on the CHA2DS2-VASc and HAS-BLED scores. The relative efficacies of LAAC and aspirin, as well as utility scores, were obtained from the published literature. Canadian procedural and long-term costs were obtained from the Ontario Case Costing Initiative and the Ontario Ministry of Health and Long Term Care. RESULTS:Aspirin was less effective than LAAC (4.25 ± 0.53 vs 4.66 ± 0.34 quality-adjusted life years, respectively). The average discounted lifetime cost was CAD$30,748 ± 11,600 for LAAC and $38,974 ± 18,783 for aspirin. Thus, LAAC was dominant, being more effective and less expensive. Our results were robust with a relatively low degree of uncertainty, as LAAC was the preferred option in more than 90% of simulations at a willingness-to-pay threshold of $50,000. CONCLUSIONS:LAAC is a novel stroke preventative therapy for nonvalvular AF and is a cost-effective alternative to aspirin in patients with contraindications to OAC.
Authors: John K Peel; Rafael Neves Miranda; David Naimark; Graham Woodward; Mamas A Mamas; Mina Madan; Harindra C Wijeysundera Journal: J Am Heart Assoc Date: 2022-04-12 Impact factor: 6.106