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Cost-Effectiveness of Radiofrequency Catheter Ablation for Atrial Fibrillation

Paul S. Chan, MD, MSc^_*,,_*, Sandeep Vijan, MD, MSc^,, Fred Morady, MD^_* and Hakan Oral, MD^_*

^_* Division of Cardiology, University of Michigan School of Medicine, Ann Arbor, Michigan
VA Center for Practice Management and Outcomes Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan

View larger version (24K): [in a new window]   Figure 1 Simplified diagram of the Markov decision-analytic model. The square at the left represents the three treatment strategy choices. The M represents the Markov process, which leads to one of many health states. The circles represent chance events that may occur in each cycle (e.g., remain well, stroke, hemorrhage, drug toxicity, reversion to atrial fibrillation—not shown) and results in continued good health or one of several disabling states. The branch from Well illustrates these chance events. Health states in the figure are simplified, and each represents multiple states in the actual model (e.g., "disabled" includes separate health states in atrial fibrillation or sinus rhythm with mild or moderate-to-severe disability due to stroke, hemorrhage, left atrial catheter ablation [LACA] complications, or drug toxicity). ICH = intracranial hemorrhage.

View larger version (32K): [in a new window]   Figure 2 Main threshold analyses. Varying left atrial catheter ablation (LACA) efficacy rates and annual stroke risks with normal sinus rhythm (NSR) restoration are determined for incremental cost-effectiveness thresholds of $50,000 (diamonds) and $100,000 (squares) per quality-adjusted life-year for 65-year-old (A) and 55-year-old (B) subjects at moderate risk for stroke. For each LACA efficacy rate, LACA would be cost-effective at a specific threshold with stroke risks at or below the threshold lines.

View larger version (27K): [in a new window]   Figure 3 Threshold analyses using less conservative model estimates. Threshold analyses were repeated with less conservative estimates for normal sinus rhythm (NSR) restoration with rate control therapy (A), health state utility for atrial fibrillation (B), and annual cost of rate control therapy (C). Analyses shown are for the 65-year-old moderate stroke-risk cohort for a $50,000 per quality-adjusted life-year cost-effectiveness threshold. Diamonds = base-case; squares = less conservative estimate; LACA = left atrial catheter ablation.

View larger version (21K): [in a new window]   Figure 4 Tornado diagram of variables with significant influence on incremental cost-effectiveness for the moderate stroke-risk cohorts. Variables identified in one-way sensitivity analysis with the largest impact on incremental cost-effectiveness are depicted. The analysis compares left atrial catheter ablation (LACA) with rate control therapy for 65-year-old (solid bars) and 55-year-old (ruled bars) moderate stroke-risk cohorts. AF = atrial fibrillation; QALY = quality-adjusted life-year.