Atrial fibrillation AF is the most common sustained cardiac arrhythmia. It places an enormous burden on the patients, caregivers and the society at large. As a chronic illness, AF accrues significant costs related to clinical presentation, complications and loss of productivity. Novel invasive approaches to AF promise a cure in some patients and a significant reduction in AF burden in others, but are very expensive. This paper will address the cost of conventional and invasive strategies in AF care and will review the evidence on the comparative cost effectiveness of these approaches.
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Atrial fibrillation AF is the most common sustained cardiac arrhythmia. It places an enormous burden on the patients, caregivers and the society at large. As a chronic illness, AF accrues significant costs related to clinical presentation, complications and loss of productivity. Novel invasive approaches to AF promise a cure in some patients and a significant reduction in AF burden in others, but are very expensive.
This paper will address the cost of conventional and invasive strategies in AF care and will review the evidence on the comparative cost effectiveness of these approaches. Atrial fibrillation AF is responsible for most arrhythmia related hospital admissions [ 1 ] and is the most common cause of ischemic stroke [ 2 ].
Furthermore, AF carries a tremendous negative impact on the quality of life and is associated with increased mortality [ 3 ]. Its prevalence is rising in our ageing society [ 4 , 5 ] and so does the expense related to its management [ 6 ] and productivity lost among the suffering patients [ 7 ]. AF related complications and disability as well as AF treatment strategies contribute to a tremendous cost to the healthcare system and the society at large with system cost attributable to AF of over 2 billion US dollars spent only on the care of patients with AF-related strokes in the US Medicare system, and a total estimated medical expenditure related to AF around 6.
The exact economic burden of AF is hard to define. This analysis stratified patients according to therapeutic strategy — rate or rhythm control — as well as according to concomitant congestive heart failure symptoms. Non-invasive therapeutic strategies for AF address restoration and maintenance of sinus rhythm, control of the ventricular rate and antithrombotic strategies directed at prevention of strokes and other embolic events.
While historically invasive therapy for AF involved primarily elimination of AV nodal conduction and right ventricular pacing, this strategy is now reserved for only a minority of patients where AF cannot be managed by other means.
Another invasive strategy aims to minimize the risk of embolic events and involves mechanical elimination or closure of the left atrial appendage LAA , the area where clots related to atrial fibrillation most commonly form. Techniques for LAA closure or excision have been initially developed by the cardiac surgeons [ 14 ].
Novel LAA closure devices have recently shown promise in reducing the risk of stroke in patients who cannot take antithrombotic agents and can be placed percutaneously [ 15 ]. Finally, AF ablation targeting the pulmonary veins, responsible for most AF episodes and other special regions thought to promote the arrhythmia has become the mainstream invasive approach to the management of this condition.
This review will address the comparative cost effectiveness of AF ablation against that of conservative care. Prevention of embolic complications is the most important aspect of care for AF patients. These range from transient ischemic events TIA to strokes and are the most costly complication of atrial fibrillation.
Strokes secondary to AF are more severe than those secondary to atherosclerotic disease and impart a greater disability on the victims [ 6 ]. This results in significant costs related to hospitalizations, rehabilitation and chronic disability. Strategies aimed at reducing embolic events in AF patients include therapy with aspirin, combination of aspirin and clopidogrel, and oral anticoagulation therapy with warfarin or one of the new agents targeting either thrombin or Factor IIa [ 16 - 18 ].
In the study of Dagibatran vs Warfarin in Patients with Atrial Fibrillation RE-LY the use of dabigatran, a direct thrombin inhibitor, was associated with similar rates of stroke and systemic embolism but lower rate of major bleeding compared to warfarin at a lower dose of mg, while the higher dose of the drug at mg was associated with lower rates of stroke and systemic embolism but similar rates of major bleeding compared to warfarin [ 18 ]. Several studies have addressed the cost of anticoagulation therapies and their complications.
Novel antithrombotic agents have been shown to further reduce the incidence of stroke and systemic embolism as well as that of major and particularly intracranial bleeding compared to warfarin. These agents do not require monitoring but carry a greater upfront cost.
Several studies evaluated cost effectiveness of these therapies compared to warfarin. Shah and colleagues found dabigatran, a direct thrombin inhibitor cost effective compared to warfarin at a higher dose of mg twice per day based on the findings of the Randomized Evaluation of Long Term Anticoagulation Therapy RE-LY study using Markov analysis [ 22 ].
Their findings were supported by Pink and colleagues in a similar analysis in the UK context [ 23 ]. There has not been a systematic cost-effectiveness evaluation of the surgical left atrial appendageal exclusion or its percutaneous occlusion compared to conventional therapy. From the outset of clinical investigation into AF management it made common sense to pursue normal sinus rhythm as the goal for most patients.
It seemed only natural that patients in sinus rhythm should fare better than those in AF. A number of studies set out to compare outcomes in patients treated with the goal to achieve sinus rhythm or remain in atrial fibrillation with a controlled ventricular response. As a surprise to many, these studies uniformly showed little advantage to the strategy of rhythm maintenance [ 24 - 27 ]. Patients who were able to achieve and maintain sinus rhythm, regardless of therapeutic strategy assignment had more favorable outcomes than those who stayed in atrial fibrillation [ 28 , 29 ], however, all evidence pointed to the greater cost-effectiveness of rate control driven largely by higher hospitalization rate among patients treated with the rhythm control strategy [ 30 - 32 ].
Dronedarone, a novel antiarrhythmic agent developed on the basis of the amiodarone molecule [ 33 ] received special attention with the Effect of Dronedarone on Cardiovascular Events in Atrial Fibrillation ATHENA study showing significant reduction in AF related hospitalizations with a hazard ratio of 0. Unfortunately, this estimate hinged on the assumption that dronedarone reduced mortality, an assumption now known to be false in at least two groups of patients; those with a history of congestive heart failure with or without persistent AF [ 34 , 35 ].
This latter model took into account the costs associated with amiodarone toxicity and stroke but not the cost of AF follow-up among the medically treated patients. The advent of catheter ablation for atrial fibrillation has come on the heels of AF surgery introduced by Dr. J Cox in Surgical ablation has been studied as a stand-alone procedure as well as an addition to other heart surgery, typically involving the mitral valve.
This latter application is responsible for most of these procedures to date and has been shown to be both effective and safe apart from a greater requirement for permanent pacing following surgical ablation for AF [ 41 ].
Catheter ablation has rapidly moved to the mainstream of AF therapy. This approach is based on the notion that paroxysmal AF episodes arise as a result of focal firing in the pulmonary veins and elsewhere in the left and right atria [ 44 ]. Nevertheless, studies of AF ablation have uniformly found improved quality of life among ablated patients.
Some of these studies have also demonstrated a significant reduction in resource utilization [ 47 ] following ablation as well as a reduction in the risk of stroke and mortality [ 48 ]. Several studies estimated the cost of the catheter ablation procedure [ 36 , 49 , 50 ]. Cost of ablation typically accounts for the use of hospital resources, catheters, physician fees, associated tests and complications of the procedure.
Since many patients may require further ablation due to downstream arrhythmia recurrences, the costs associated with these have to be factored in as well. In an analysis of Medicare patients followed for a year after ablation, Kim et al.
Several projections of cost of care of an AF patient have been published in an attempt to estimate the relative cost of ablation and contrast it to the cost of medical therapy over time [ 36 , 50 ].
A study directly comparing the costs of ablation and medical therapy in the Canadian healthcare environment has been published [ 36 ]. Costs related to medical therapy in the analysis included the cost of anticoagulation, rate and rhythm control medications, non-invasive testing, physician follow-up visits and hospital admissions, as well as the cost of complications related to this management strategy. Costs related to catheter ablation were assumed to include the cost of the ablation tools electroanatomic mapping or intracardiac echocardiography-guided pulmonary vein ablation , hospital and physician billings, costs related to periprocedural medical care and complications.
The study projected costs of ongoing medical therapy and catheter ablation to equalize at 3. Six groups of investigators attempted to perform a cost-benefit analysis of AF ablation with that of medical therapy [ 37 , 51 - 55 ]. In the first of these studies, a Markov decision analysis model looking at 55 and year-old cohorts of patients at low and moderate risk of stroke was created by the investigators [ 51 ]. Complications and costs related to AF, medical therapy and catheter ablation were accounted for.
The model assumed that amiodarone would be used for rhythm control and a combination of digoxin and atenolol — for rate control. Moderate risk of stroke was defined as having one risk factor, including diabetes, hypertension, coronary artery disease, or congestive heart failure. Patients at low risk of stroke were assumed to have no such risk factors. For the purpose of the model, patients at moderate risk of stroke were anticoagulated whereas those at low risk could be on warfarin or aspirin.
The model incorporated annual stroke risk of 2. A relative stroke risk of 1. Age adjusted mortality based on life tables and mortality reductions attributable to aspirin and warfarin were accounted for.
Costs were estimated based on Medicare reimbursement rates, hospital accounting information, published literature and the Red Book for wholesale drug costs. Unfortunately, while there is no prospective data on the efficacy of ablation for prevention of thromboembolic events, the findings of this study are conditional on such evidence coming to light in the years to come. Eckard et al. The authors used a decision tree for the initial year in which the RFA procedure is assumed to take place, and a long-term Markov structure for subsequent years.
The authors factored in the potential for a second ablation within a year of the first procedure in patients still suffering from AF. In order to estimate QALY weights for different health states, age-adjusted QALY weights based on a Swedish general population were applied for patients in the controlled AF state, and used as reference points.
A decrement of 0. Further sensitivity analyses found the estimate to depend significantly both on the relative QOL estimate associated with sinus rhythm and on the prognostic implications of being in rhythm [ 53 ]. Reynolds and his group published a Markov model cost effectiveness analysis of ablation vs antiarhrtyhmic therapy in a simulated cohort of patients with paroxysmal drug refractory AF projected over 5 years [ 54 ]. Amiodarone therapy was used as control.
Utility estimates in the model were based on the work published by Reynolds et al. It was assumed that patients in sinus rhythm would be at a lower risk of stroke compared to those in atrial fibrillation.
Investigators also assumed that successfully ablated patients would discontinue anticoagulation. Ablated patients were assumed to undergo 1. Cost of medical care was comprised of the cost of amiodarone therapy, warfarin therapy and monitoring.
It accounted for the cost of strokes and major bleeding as well as pulmonary toxicity. Cost of ablation accounted for the risk of procedural complications. Based on the model, AF ablation would become cost-effective after 5 years of follow-up. The findings supported earlier publications from our group ranging the break-even point for the cost of AF ablation and medical therapy at 3.
All of these models support cost effectiveness of AF ablation in older patients at a moderate risk of stroke with similar derived ICERs despite slightly different methodology. At the same time, most patients ablated to-date have been younger with a very low risk of stroke, but a significant impairment in the quality of life associated with AF. None of the models accounted for the use of novel antithrombotic medications nor for the significant late success attrition rates among ablated patients.
Detailed cost studies should be tied to prospective investigation of the outcomes in the studies of atrial fibrillation management as new therapeutic agents and invasive technology become available.
Atrial fibrillation is a common condition with numerous clinical implications. Medical and invasive strategies for this condition are evolving rapidly. While more expensive up front, ablation appears to be a cost-effective alternative to the non-invasive AF treatment strategies after a year time horizon. Future studies comparing clinical outcomes in patients treated using ablation or medical therapy should collect detailed cost data at the patient level to enable a more precise cost-effectiveness analysis.
The authors confirm that this article content has no conflicts of interest. National Center for Biotechnology Information , U. Journal List Curr Cardiol Rev v. Curr Cardiol Rev.
Published online Nov. Author information Article notes Copyright and License information Disclaimer.
MALIYET MUHASEBESI AF PDF
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Cost of Atrial Fibrillation: Invasive vs Non-Invasive Management in 2012
En al costs may nmental activ me time, cost environment mental protec n in Figure 2. Kan OKC forvente et spor til 1 af sne 48C6 of going back to school for another career and they choose the Community College route or because of the cost. The condition contributes to an muhxsebesideaths each year. To meet your needs and optimize your operations, our ambition is to work together with you throughout the entire process. The Classify prototype helps librarians apply classification numbers to resources in library collections.