CLINICAL RESERACH: ATRIAL FIBRILLATION
Economic analysis of a transesophageal echocardiography-guided approach to cardioversion of patients with atrial fibrillation
The ACUTE economic data at eight weeks
Allan L. Klein, MD, FACC*,*,
R. Daniel Murray, PhD*,
Edmund R. Becker, PhD ,
Steven D. Culler, PhD,
William S. Weintraub, MD, FACC,
Susan E. Jasper, RN, BSN*,
Elizabeth A. Lieber, BA ,
Carolyn Apperson-Hansen, MStat,
Adrienne M. Heerey, PhD*,
Richard A. Grimm, DO, FACC* ACUTE Investigators
* Department of Cardiovascular Medicine, the Cleveland Clinic Foundation, Cleveland, Ohio, USA
Department of Biostatistics and Epidemiology, the Cleveland Clinic Foundation, Cleveland, Ohio, USA
Department of Cardiology, School of Medicine and the Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
Manuscript received September 25, 2002;
revised manuscript received February 28, 2003,
accepted November 17, 2003.
* Reprint requests and correspondence: Dr. Allan L. Klein, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Desk F15, Cleveland, Ohio 44195, USA.
kleina{at}ccf.org
OBJECTIVES: The aim of this study was to compare the relative cost of a transesophageal echocardiography (TEE)-guided strategy versus conventional strategy for patients with atrial fibrillation (AF) >2 days duration undergoing electrical cardioversion over an eight-week period.
BACKGROUND: The Assessment of Cardioversion Using Transesophageal Echocardiography (ACUTE) trial found no difference in embolic rates between the two approaches. However, the TEE-guided strategy had a shorter time to cardioversion and a lower rate of composite bleeding. While similar clinical efficacy was concluded, the relative cost of these two strategies has not been explored.
METHODS: Two economic approaches were employed in the ACUTE trial. The first approach was based on hospital charge data from complete hospital Universal Billing Code of 1992 forms, a detailed hospital charge questionnaire, or imputation. Regression analysis was used to investigate the added cost of adverse events. The second economic approach involved the development of an independent analytic model simulating treatment and actual ACUTE outcome costs as a validation of clinically derived data. Sensitivity analysis was performed on the analytic model to investigate the potential range in cost differences between the strategies.
RESULTS: A total of 833 of the 1,222 patients were enrolled from 53 U.S. sites; TEE-guided (n = 420) and conventional (n = 413). At eight-week follow-up, total mean costs did not significantly differ between the two groups, respectively ($6,508 vs. $6,239; difference of $269; p = 0.50). Cumulative costs were 24% higher in the conventional group, primarily due to increased incidence of bleeding and hospital costs associated with bleeding. A separate analytic model showed that treatment costs were higher for the TEE-guided strategy, but outcome costs were higher for the conventional strategy. Sensitivity analysis of the analytic model illustrated that varying the incidence and cost of major bleeding and the cost of TEE had the greatest impact on cost differences between the two groups.
CONCLUSIONS: In patients with AF >2 days duration undergoing electrical cardioversion, the TEE-guided group showed little difference in patient costs compared with the conventional group. The TEE strategy had higher initial treatment costs but lower outcome-associated costs. Cumulative costs were 24% higher in the conventional group, primarily due to bleeding. The TEE-guided strategy is an economically feasible approach compared with the conventional strategy.
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Abbreviations and Acronyms
| | ACUTE | = Assessment of Cardioversion Using Transesophageal Echocardiography trial | | AF | = atrial fibrillation | | CPI | = Consumer Price Index | | ICER | = incremental cost-effectiveness ratio | | QALY | = quality-adjusted life year | | TEE | = transesophageal echocardiography | | TTE | = transthoracic echocardiography | | UB92 | = Universal Billing Code of 1992 |
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