Catheter ablation (CA) for atrial fibrillation (AF) is a procedure with high up-front costs but is superior to pharmacologic treatments for reducing symptoms1 and hospital presentations2. In patients with mild symptoms or few hospitalisations the cost of CA may not be justified.
However, for patients with severe symptoms and/or frequent hospital admissions CA could be preferred when downstream health system costs and quality of life are taken into account. Several international cost effectiveness analyses have been published on CA for AF3, but few have stratified the target patient group by hospitalisations avoided, or by heterogeneity of quality of life gained.
Adapt Research developed a macroeconomic model to define a patient population for whom CA is economically rational.
We compared scenarios where CA is offered to different sub-groups of patients with AF. International literature and local New Zealand health system data informed heterogeneity of procedure success by type of AF, time since procedure, and age of patient. Disability weight and number of hospital presentations were varied. Costs of CA, downstream outpatient care, and subsequent hospitalisations were estimated from New Zealand health datasets and international literature. CA and pharmacologic management were compared to obtain incremental cost-effectiveness ratios (ICERs). Scenarios were modeled over five years and no difference in the rate of mortality or stroke was assumed between CA and drug treatment.
It turns out that the ICER for CA compared to pharmacologic management ranged from cost-saving to NZD$169,308 (USD$112,680).
Variables tending to increase the ICER were: lower cost of drug treatment, increased cost of CA, offering CA to older patients, and to those with non-paroxysmal AF.
Variables tending to decrease the ICER were lower procedure cost, increased disability weight assigned to AF, and increased number of hospitalisations avoided.
The ICER under present provision in New Zealand is estimated to be NZD$55,994 (USD$37,249). Targeting only those patients with the most severe symptoms reduces the ICER to NZD$35,750 (USD$23,782).
CA is cost-saving for patients having more than one hospitalisation per year for AF.
If QALYs and absentee days are monetized using GDP, then CA for a wide range of patients is cost-saving from a societal perspective. Time to recoup costs ranged from zero to 17 years.
So it seems that the cost-effectiveness of CA for AF is highly dependent on the patient population to whom CA is offered. This is important given heterogeneity of the target population. Using severity of AF scales4, which have been validated against quality of life metrics and number of hospital presentations, could help identify an appropriate target patient group.
Click here to request a copy of our full technical report.
References: 1 Shi, LZ. et al. 2015. Exp Ther Med, 10(2):816-22. 2 Bulkova, V. et al. 2014. J Am Heart Assoc, 3(4) e000881. 3 Neyt, M. et al. 2013. BMC Cardiovasc Disord, 13(78). 4 Ha, AC. et al. 2013. J Interv Card Electrophysiol, 36(2):177-84.