Derek S Chew1, Zak Loring1,2, Jatin Anand3, Marat Fudim1,2, Angela Lowenstern1,2, Jennifer A Rymer1,2, Kristin E D Weimer4, Brett D Atwater2, Adam D DeVore1,2, Derek V Exner5, Peter A Noseworthy6, Clyde W Yancy7, Daniel B Mark1,2, Jonathan P Piccini1,2. 1. Duke Clinical Research Institute, Duke University, Durham, NC (D.S.C., Z.L., M.F., A.L., J.A.R., A.D.D., D.B.M., J.P.P.). 2. Division of Cardiology (Z.L., M.F., A.L., J.A.R., B.D.A., A.D.D., D.B.M., J.P.P.), Duke University Medical Center, Durham, NC. 3. Division of Cardiovascular and Thoracic Surgery, Department of Surgery (J.A.), Duke University Medical Center, Durham, NC. 4. Department of Pediatrics (K.E.D.W.), Duke University Medical Center, Durham, NC. 5. Department of Cardiac Sciences, University of Calgary, Alberta, Canada (D.V.E.). 6. Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (P.A.N.). 7. Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (C.W.Y.).
Abstract
BACKGROUND: Randomized clinical trials have demonstrated that catheter ablation for atrial fibrillation in patients with heart failure with reduced ejection fraction may improve survival and other cardiovascular outcomes. METHODS: We constructed a decision-analytic Markov model to estimate the costs and benefits of catheter ablation and medical management in patients with symptomatic heart failure with reduced ejection fraction (left ventricular ejection fraction ≤35%) and atrial fibrillation over a lifetime horizon. Evidence from the published literature informed the model inputs, including clinical effectiveness data from meta-analyses. Probabilistic and deterministic sensitivity analyses were performed. A 3% discount rate was applied to both future costs and benefits. The primary outcome was the incremental cost-effectiveness ratio assessed from the US health care sector perspective. RESULTS: Catheter ablation was associated with 6.47 (95% CI, 5.89-6.93) quality-adjusted life years (QALYs) and a total cost of $105 657 (95% CI, $55 311-$191 934; 2018 US dollars), compared with 5.30 (95% CI, 5.20-5.39) QALYs and $63 040 (95% CI, $37 624-$102 260) for medical management. The incremental cost-effectiveness ratio for catheter ablation compared with medical management was $38 496 (95% CI, $5583-$117 510) per QALY gained. Model inputs with the greatest variation on incremental cost-effectiveness ratio estimates were the cost of ablation and the effect of catheter ablation on mortality reduction. When assuming a more conservative estimate of the treatment effect of catheter ablation on mortality (hazard ratio of 0.86), the estimated incremental cost-effectiveness ratio was $74 403 per QALY gained. At a willingness-to-pay threshold of $100 000 per QALY gained, atrial fibrillation ablation was found to be economically favorable compared with medical management in 95% of simulations. CONCLUSIONS: Catheter ablation in patients with heart failure with reduced ejection fraction patients and atrial fibrillation may be considered economically attractive at current benchmarks for societal willingness-to-pay in the United States.
BACKGROUND: Randomized clinical trials have demonstrated that catheter ablation for atrial fibrillation in patients with heart failure with reduced ejection fraction may improve survival and other cardiovascular outcomes. METHODS: We constructed a decision-analytic Markov model to estimate the costs and benefits of catheter ablation and medical management in patients with symptomatic heart failure with reduced ejection fraction (left ventricular ejection fraction ≤35%) and atrial fibrillation over a lifetime horizon. Evidence from the published literature informed the model inputs, including clinical effectiveness data from meta-analyses. Probabilistic and deterministic sensitivity analyses were performed. A 3% discount rate was applied to both future costs and benefits. The primary outcome was the incremental cost-effectiveness ratio assessed from the US health care sector perspective. RESULTS: Catheter ablation was associated with 6.47 (95% CI, 5.89-6.93) quality-adjusted life years (QALYs) and a total cost of $105 657 (95% CI, $55 311-$191 934; 2018 US dollars), compared with 5.30 (95% CI, 5.20-5.39) QALYs and $63 040 (95% CI, $37 624-$102 260) for medical management. The incremental cost-effectiveness ratio for catheter ablation compared with medical management was $38 496 (95% CI, $5583-$117 510) per QALY gained. Model inputs with the greatest variation on incremental cost-effectiveness ratio estimates were the cost of ablation and the effect of catheter ablation on mortality reduction. When assuming a more conservative estimate of the treatment effect of catheter ablation on mortality (hazard ratio of 0.86), the estimated incremental cost-effectiveness ratio was $74 403 per QALY gained. At a willingness-to-pay threshold of $100 000 per QALY gained, atrial fibrillation ablation was found to be economically favorable compared with medical management in 95% of simulations. CONCLUSIONS: Catheter ablation in patients with heart failure with reduced ejection fraction patients and atrial fibrillation may be considered economically attractive at current benchmarks for societal willingness-to-pay in the United States.
Authors: Michael R MacDonald; Derek T Connelly; Nathaniel M Hawkins; Tracey Steedman; John Payne; Morag Shaw; Martin Denvir; Sai Bhagra; Sandy Small; William Martin; John J V McMurray; Mark C Petrie Journal: Heart Date: 2010-11-04 Impact factor: 5.994
Authors: Sean D Pokorney; DaJuanicia N Holmes; Peter Shrader; Laine Thomas; Gregg C Fonarow; Kenneth W Mahaffey; Bernard J Gersh; Peter R Kowey; Gerald V Naccarelli; James V Freeman; Daniel E Singer; Jeffrey B Washam; Eric D Peterson; Jonathan P Piccini; James A Reiffel Journal: Am Heart J Date: 2019-10-23 Impact factor: 4.749
Authors: Zain Ul Abideen Asad; Ali Yousif; Muhammad Shahzeb Khan; Sana M Al-Khatib; Stavros Stavrakis Journal: Circ Arrhythm Electrophysiol Date: 2019-08-21
Authors: Sandeep Prabhu; Andrew J Taylor; Ben T Costello; David M Kaye; Alex J A McLellan; Aleksandr Voskoboinik; Hariharan Sugumar; Siobhan M Lockwood; Michael B Stokes; Bhupesh Pathik; Chrishan J Nalliah; Geoff R Wong; Sonia M Azzopardi; Sarah J Gutman; Geoffrey Lee; Jamie Layland; Justin A Mariani; Liang-Han Ling; Jonathan M Kalman; Peter M Kistler Journal: J Am Coll Cardiol Date: 2017-08-27 Impact factor: 24.094
Authors: Matthew R Reynolds; Peter Zimetbaum; Mark E Josephson; Ethan Ellis; Tatyana Danilov; David J Cohen Journal: Circ Arrhythm Electrophysiol Date: 2009-04-17
Authors: Gillian D Sanders; Peter J Neumann; Anirban Basu; Dan W Brock; David Feeny; Murray Krahn; Karen M Kuntz; David O Meltzer; Douglas K Owens; Lisa A Prosser; Joshua A Salomon; Mark J Sculpher; Thomas A Trikalinos; Louise B Russell; Joanna E Siegel; Theodore G Ganiats Journal: JAMA Date: 2016-09-13 Impact factor: 56.272
Authors: Clare J Taylor; José M Ordóñez-Mena; Andrea K Roalfe; Sarah Lay-Flurrie; Nicholas R Jones; Tom Marshall; F D Richard Hobbs Journal: BMJ Date: 2019-02-13
Authors: Stephan Willems; Christian Meyer; Joseph de Bono; Axel Brandes; Lars Eckardt; Arif Elvan; Isabelle van Gelder; Andreas Goette; Michele Gulizia; Laurent Haegeli; Hein Heidbuchel; Karl Georg Haeusler; Josef Kautzner; Lluis Mont; G Andre Ng; Lukasz Szumowski; Sakis Themistoclakis; Karl Wegscheider; Paulus Kirchhof Journal: Eur Heart J Date: 2019-12-07 Impact factor: 29.983
Authors: Derek S Chew; Yanhong Li; Patricia A Cowper; Kevin J Anstrom; Jonathan P Piccini; Jeanne E Poole; Melanie R Daniels; Kristi H Monahan; Linda Davidson-Ray; Tristram D Bahnson; Hussein R Al-Khalidi; Kerry L Lee; Douglas L Packer; Daniel B Mark Journal: Circulation Date: 2022-06-21 Impact factor: 39.918