Cost-effectiveness of radiofrequency ablation versus percutaneous ethanol injection for early hepatocellular carcinoma in a resource-poor setting: a randomized trial

OBJECTIVE

This study assessed the cost-effectiveness of radiofrequency ablation compared with percutaneous ethanol injection in patients with early hepatocellular carcinoma in relation to the objective response rate and costs related to the procedure.

METHODS

This was a prospective single-center randomized trial. The primary outcome was cost-effectiveness. Secondary outcomes were the complete response rate according to the modified response evaluation criteria in solid tumors 60 days after randomization and the complication rate within 180 60 days.

RESULTS

Fifty patients were placed into the following groups: percutaneous ethanol injection (n=23) and radiofrequency ablation (n=27). Fifty-four nodules were randomized (mean follow-up: 205.37 days). The estimated mean hospital cost was US$ 1854.11 and US$ 2770.96 for the Radiofrequency Ablation and Percutaneous Ethanol Injection Groups, respectively. The incremental cost-effectiveness ratio was US$ -2674.59, which is advantageous for radiofrequency ablation. After 60 d, 28 of 29 nodules in the Radiofrequency Ablation Group achieved complete response versus 12 of 22 in the Percutaneous Ethanol Injection Group (RD, 42.01 [95%CI= 20.55-63.24]; p<0.001). Only four early complications were observed among patients treated by percutaneous ethanol injection (p<0.05). Late complications occurred in two and one patient(s) in the Radiofrequency Ablation and Percutaneous Ethanol Injection Groups (p>0.05), respectively.

CONCLUSION

Radiofrequency ablation was more cost-effective and achieved higher complete response and lower complication rates than the Percutaneous Ethanol Injection Group within this cohort.

REGISTRY OF CLINICAL TRIALS

NCT06450613.

Cost, efficiency, and outcomes of pulsed field ablation vs thermal ablation for atrial fibrillation: A real-world study

BACKGROUND

With the exponential growth of catheter ablation for atrial fibrillation (AF), there is increasing interest in associated health care costs. Pulsed field ablation (PFA) using a single-shot pentaspline multielectrode catheter has been shown to be safe and effective for AF ablation, but its cost efficiency compared to conventional thermal ablation modalities (cryoballoon [CB] or radiofrequency [RF]) has not been evaluated.

OBJECTIVE

The purpose of this study was to compare cost, efficiency, effectiveness, and safety between PFA, CB, and RF for AF ablation.

METHODS

We studied 707 consecutive patients (PFA: 208 [46.0%]; CB: 325 [29.4%]; RF: 174 [24.6%]) undergoing first-time AF ablation. Individual procedural costs were calculated, including equipment, laboratory use, and hospital stay, and compared between ablation modalities, as were effectiveness and safety.

RESULTS

Skin-to-skin times and catheter laboratory times were significantly shorter with PFA (68 and 102 minutes, respectively) than with CB (91 and 122 minutes) and RF (89 and 123 minutes) (P < .001). General anesthesia use differed across modalities (PFA 100%; CB 10.2%; RF 61.5%) (P < .001). Major complications occurred in 1% of cases, with no significant differences between modalities. Shorter procedural times resulted in lower staffing and laboratory costs with PFA, but these savings were offset by substantially higher equipment costs, resulting in higher overall median costs with PFA (£10,010) than with CB (£8106) and RF (£8949) (P < .001).

CONCLUSION

In this contemporary real-world study of the 3 major AF ablation modalities used concurrently, PFA had shorter skin-to-skin and catheter laboratory times than did CB and RF, with similarly low rates of complications. However, PFA procedures were considerably more expensive, largely because of higher equipment cost.

Long-term clinical outcomes and cost-effectiveness of catheter vs thoracoscopic surgical ablation in long-standing persistent atrial fibrillation using continuous cardiac monitoring: CASA-AF randomized controlled trial

BACKGROUND

Long-term clinical outcomes of catheter ablation (CA) compared to thoracoscopic surgical ablation (SA) to treat patients with long-standing persistent atrial fibrillation (LSPAF) are not known.

OBJECTIVE

The purpose of this study was to compare the long-term (36-month) clinical efficacy, quality of life, and cost-effectiveness of SA and CA in LSPAF.

METHODS

Participants were followed up for 3 years using implantable loop recorders and questionnaires to assess the change in quality of life. Intention-to-treat analyses were used to report the findings.

RESULTS

Of the 115 patients with LSPAF treated, 104 (90.4%) completed 36-month follow-up [CA: n = 57 (95%); SA: n = 47 (85%)]. After a single procedure without antiarrhythmic drugs, 7 patients (12%) in the CA arm and 5 (11%) in the SA arm [hazard ratio 1.22; 95% confidence interval (CI) 0.81-1.83; P = .41] were free from atrial fibrillation/tachycardia (AF/AT) ≥30 seconds at 36 months. Thirty-three patients (58%) in the CA arm and 26 (55%) in the SA arm (hazard ratio 1.04; 95% CI 0.57-1.88; P = .91) had their AF/AT burden reduced by ≥75%. The overall impact on health-related quality of life was similar, with mean quality-adjusted life year estimates of 2.45 (95% CI 2.31-2.59) for CA and 2.32 (95% CI 2.13-2.52) for SA. Estimated costs were higher for SA (mean £24,682; 95% CI £21,746-£27,618) than for CA (mean £18,002; 95% CI £15,422-£20,581).

CONCLUSION

In symptomatic LSPAF, CA and SA were equally effective at achieving arrhythmia outcomes (freedom from AF/AT ≥30 seconds and ≥75% burden reduction) after a single procedure without antiarrhythmic drugs. However, SA is significantly more costly than CA.

Comprehensive analysis of same day discharge after atrial fibrillation ablation: Clinical, cost, and patient reported outcomes

BACKGROUND

Same day discharge (SDD) following atrial fibrillation (AF) ablation procedure has emerged as routine practice, and primarily driven by operator discretion. However, the impacts of SDD on clinical outcomes, healthcare system costs, and patient reported outcomes (PROs) have not been systematically studied.

METHODS

We retrospectively analyzed patients undergoing routine AF ablation procedures with SDD versus overnight observation (NSDD). After propensity adjustment we compared postprocedure adverse events (AEs), healthcare system costs, and changes in PROs.

RESULTS

We identified 310 cases, with 159 undergoing SDD and 151 staying at least one midnight in the hospital (NSDD). Compared with NSDD, SDD patients were similar age (mean 64 vs. 66, p = 0.3), sex (26% female vs. 27%, p = 0.8), and with lower mean CHADS2-VA2Sc scores (2.0 vs. 2.7; p < 0.011). The primary outcome of AEs was noninferior in SDD versus NSDD patients (odds ratio 0.45, 95% confidence interval 0.21-0.99; noninferiority margin of 10%). There were also no differences in overall cost to the healthcare system between SDD and NSDD (p = 0.11). PROs numerically favored SDD (p = NS for all scores).

CONCLUSIONS

Physician selection for SDD appears at least as safe as NSDD with respect to clinical outcomes and SDD is not significantly less costly to the health system. There is a trend towards more favorable, general PROs among SDD patients. Routine SDD should be strongly considered for patients undergoing routine AF ablation procedures.

Impact of COVID-19 pandemic on the volume, cost, and outcomes of cardiac electrophysiology procedures in the United States

BACKGROUND

During the COVID-19 pandemic, professional societies recommended deferral of elective procedures for optimal resource utilization.

OBJECTIVE

We sought to assess changes in procedural trends and outcomes of electrophysiology (EP) procedures during the pandemic.

METHODS

National Inpatient Sample databases were used to identify all EP procedures performed in the United States (2016-2020) by International Classification of Diseases, Tenth Revision codes. We evaluated trends in utilization, cost/revenue, and outcomes from EP procedures performed.

RESULTS

An estimated 1.35 million EP procedures (82% devices and 18% catheter ablations) were performed (2016-2020) with significant yearly uptrend. During the pandemic, there was a substantial decline in EP procedure utilization from a 5-year peak of 298 cases/million population in the second quarter of 2019 to a nadir of 220 cases in the second quarter of 2020. In 2020, the pandemic was associated with the loss of 50,233 projected EP procedures (39,337 devices and 10,896 ablations) with subsequent revenue loss of $7.06 billion. This deficit was driven by revenue deficit from dual-chamber permanent pacemaker (PPM) utilization ($2.88 billion, 49.3% of lost cases), ablation procedures ($1.84 billion, 21.7% of lost cases), and implantable cardioverter-defibrillator implantation ($1.36 billion, 12.0% of lost cases). To the contrary, there was a 9.4% increase in the utilization of leadless PPM. EP device implantation during the pandemic was associated with higher adverse in-hospital events (9.4% vs 8.0%; P < .001).

CONCLUSION

In the United States, the significant decline in EP procedures during the pandemic was primarily driven by the reduction in dual-chamber PPM utilization, followed by arrhythmia ablation and implantable cardioverter-defibrillator implantation. There was a substantial increase in leadless PPM utilization during the pandemic.

Pulsed field ablation with the pentaspline catheter compared with cryoablation for the treatment of paroxysmal atrial fibrillation in the UK NHS: a cost-comparison analysis

OBJECTIVES

Pulsed field ablation (PFA) is a promising new ablation modality for the treatment of atrial fibrillation (AF) that has recently become available in the UK National Health Service (NHS). We provide the first known economic evaluation of the technology.

METHODS

A cost-comparison model was developed to compare the expected 12-month costs of treating AF using the pentaspline PFA catheter compared with cryoablation for a single hypothetical patient. Model parameters were based on a recent cost-effectiveness analysis by the National Institute for Health and Care Excellence where possible or published literature otherwise. Deterministic sensitivity, scenario and threshold analyses were conducted.

RESULTS

Costs for a single patient treated with PFA were -3% (-£343) less over 12 months than those who received treatment with cryoablation. PFA was associated with 16% higher catheter costs but repeat ablation costs were over 50% less, driven by a reduction in repeat ablations required. Costs of managing complications were -£211 less in total for PFA compared with cryoablation.

CONCLUSIONS

Routine adoption of PFA with the pentaspline PFA catheter looks to be as affordable for the NHS as current treatment alternative cryoablation.

Editor's Choice - Short Term Cost Effectiveness of Radiofrequency Ablation and High Ligation and Stripping for Great Saphenous Vein Incompetence

OBJECTIVE

Superficial venous incompetence (SVI) is a common disease that causes significant quality of life (QoL) impairment. There is a need for more health economic evaluations of SVI treatment. The aim of this study was to perform a cost effectiveness analysis in patients with great saphenous vein (GSV) incompetence comparing radiofrequency ablation (RFA), high ligation and stripping (HL/S), and no treatment or conservative treatment with one year follow up.

METHODS

Randomised controlled trial economic analysis from an ongoing trial; 143 patients (156 limbs) with GSV incompetence (CEAP clinical class 2 - 6) were included. Treatment was performed with RFA or HL/S. Follow up was performed up to one year using duplex ultrasound, revised venous clinical severity score (r-VCSS), Aberdeen Varicose Vein Questionnaire (AVVQ), and EuroQol-5D-3L (EQ-5D-3L).

RESULTS

Seventy-eight limbs were treated with RFA and HL/S respectively. No treatment or conservative treatment was assumed to have zero in treatment cost and no treatment benefit. In the RFA group, one limb had reflux in the GSV after one month and three limbs after one year. In HL/S, two limbs had remaining reflux in the treated area at one month and one year. Both disease severity (r-VCSS, p = .004) and QoL (AVVQ, p = .021 and EQ-5D-3L, p = .028) were significantly improved over time. The QALY gain was 0.21 for RFA and 0.17 for HL/S. The cost per patient was calculated as €1 292 for RFA and €2 303 for HL/S. The cost per QALY (compared with no treatment or conservative treatment) was €6 155 for RFA and €13 549 for HL/S. With added cost for days absent from work the cost per QALY was €7 358 for RFA and €24 197 for HL/S. The cost per QALY for both methods was well below the threshold suggested by Swedish National Board of Health.

CONCLUSION

RFA is more cost effective than HL/S and no treatment or conservative treatment at one year follow up.

A cost-consequence analysis comparing three cardiac ablation strategies for the treatment of paroxysmal atrial fibrillation

BACKGROUND AND AIMS

Cardiac ablation is a well-established method for treating atrial fibrillation (AF). Pulsed field ablation (PFA) is a non-thermal therapeutic alternative to radiofrequency ablation (RFA) and cryoballoon ablation (CRYO). PFA uses high-voltage electric pulses to target cells. The present analysis aims to quantify the costs, outcomes, and resources associated with these three ablation strategies for paroxysmal AF.

METHODS

Real-world clinical data were prospectively collected during index hospitalization by three European medical centers (Belgium, Germany, the Netherlands) specialized in cardiac ablation. These data included procedure times (pre-procedural, skin-to-skin and post-procedural), resource use, and staff burden. Data regarding complications associated with each of the three treatment options and redo procedures were extracted from the literature. Costs were collected from hospital economic formularies and published cost databases. A cost-consequence model from the hospital perspective was built to estimate the impact of the three treatment options in terms of effectiveness and costs.

RESULTS

Across the three centers, N = 91 patients were included over a period of 12 months. A significant difference was seen in pre-procedural time (mean ± SD, PFA: 13.6 ± 3.7 min, CRYO: 18.8 ± 6.6 min, RFA: 20.4 ± 6.4 min; p < .001). Procedural time (skin-to-skin) was also different across alternatives (PFA: 50.9 ± 22.4 min, CRYO: 74.5 ± 24.5 min, RFA: 140.2 ± 82.4 min; p < .0001). The model reported an overall cost of €216,535 per 100 patients treated with PFA, €301,510 per 100 patients treated with CRYO and €346,594 per 100 patients treated with RFA. Overall, the cumulative savings associated with PFA (excluding kit costs) were €850 and €1,301 per patient compared to CRYO and RFA, respectively.

CONCLUSION

PFA demonstrated shorter procedure time compared to CRYO and RFA. Model estimates indicate that these time savings result in cost savings for hospitals and reduce outlay on redo procedures. Clinical practice in individual hospitals varies and may impact the ability to transfer the results of this analysis to other settings.

Contemporary procedure characteristics and outcomes of accessory atrioventricular pathway ablations in an integrated community-based health care system using a tiered approach

BACKGROUND

Since the early descriptions of large series of accessory atrioventricular pathway ablations in adults and adolescents over 20 years ago, there have been limited published reports based on more recent experiences of large referral centers. We aimed to characterize accessory pathway distribution and features in a large community-based population that influence ablation outcomes using a tiered approach to ablation.

METHODS

Retrospective analysis of 289 patients (age 14-81) who underwent accessory ablation from 2015-2019 was performed. Pathways were categorized into anteroseptal, left freewall, posteroseptal, and right freewall locations. We analyzed patient and pathway features to identify factors associated with prolonged procedure time parameters.

RESULTS

Initial ablation success rate was 94.7% with long-term success rate of 93.4% and median follow-up of 931 days. Accessory pathways were in left freewall (61.6%), posteroseptal (24.6%), right freewall (9.6%), and anteroseptal (4.3%) locations. Procedure outcome was dependent on pathway location. Acute success was highest for left freewall pathways (97.1%) with lowest case times (144 ± 68 min) and fluoroscopy times (15 ± 19 min). Longest procedure time parameters were seen with anteroseptal, left anterolateral, epicardial-coronary sinus, and right anterolateral pathway ablations.

CONCLUSIONS

In this community-based adult and adolescent population, majority of the accessory pathways are in the left freewall and posteroseptal region and tend to be more easily ablated. A tiered approach with initial use of standard ablation equipment before the deployment of more advance tools, such as irrigated tips and 3D mapping, is cost effective without sacrificing overall efficacy.

Cost-effectiveness of combined catheter ablation and left atrial appendage closure for symptomatic atrial fibrillation in patients with high stroke and bleeding risk

BACKGROUND

Combined catheter ablation (CA) and left atrial appendage closure (LAAC) have been proposed for management of symptomatic atrial fibrillation (AF) in patients with high stroke and bleeding risk. We assessed the cost-effectiveness of combined CA and LAAC compared with CA and standard oral anticoagulation (OAC) in symptomatic AF.

METHODS

A Markov model was developed to assess total costs, quality-adjusted life-years (QALYs), and the incremental cost-effectiveness ratio among 2 post-CA strategies: (1) standard OAC and (2) LAAC (combined CA and LAAC procedure). The base-case used a 10-year time horizon and consisted of a hypothetical cohort of patients aged 65 years with symptomatic AF, with high thrombotic (CHA₂DS₂-VASc = 3) and bleeding risk (HAS-BLED = 3), and planned for AF ablation. Values for transition probabilities, utilities, and costs were derived from the literature. Costs were converted to 2020 US dollars. Half-cycle correction was applied, and costs and QALYs were discounted at 3% annually. Sensitivity analyses were performed for significant variables and scenario analyses for higher embolic risk.

RESULTS

In the base-case cohort of 10,000 patients followed for 10 years, total costs for the LAAC strategy were $29,027 and for OAC strategy were $27,896. The LAAC strategy was associated with 122 fewer disabling strokes and 203 fewer intracranial hemorrhages per 10,000 patients compared with the OAC strategy. The LAAC strategy had an incremental cost-effectiveness ratio of $11,072/QALY. In sensitivity analyses, although cost-effectiveness was highly dependent on the risk of intracranial hemorrhage in the LAAC strategy and the cost of the combined procedure, LAAC was superior to OAC under the most circumstances. Scenario analyses demonstrated that the combined procedure was more cost-effective in patients with higher stroke risk.

CONCLUSIONS

In symptomatic AF patients with high stroke and bleeding risk who are planned for CA, the combined CA and LAAC procedure may be a cost-effective therapeutic option and be more beneficial to patients with CHA₂DS₂-VASc risk score ≥3.

Healthcare Resource Use and Expenditures in Patients Newly Diagnosed With Paroxysmal Supraventricular Tachycardia

Information on paroxysmal supraventricular tachycardia (PSVT) patient characteristics and the associated economic burden of the disease is limited. Therefore, we sought to characterize newly diagnosed PSVT patients and quantify their healthcare resource use and expenditures. We used enrollment, demographic, and claims data from IBM MarketScan Research Database and Medicare Limited Data Set (LDS) to identify patients newly diagnosed with PSVT (ICD-9: 427.0; ICD-10: I47.1) from 10/1/2012 to 9/30/2016. Patients were required to be observable 1-year before and after index diagnosis. Patients were stratified by age (<65 years and ≥65 years), and propensity-matched to patients without PSVT. Expenditures and healthcare resource use were analyzed 1 year before and 1-year following index diagnosis. Among 49,316 patients <65 years and 23,954 patients ≥65 years, most were female (64% and 63%, respectively). Compared with matched controls, all PSVT patients had significantly more emergency department visits pre- and postdiagnosis, and more hospitalizations following diagnosis. Mean annual per patient expenditures paid by insurers were significantly higher in the year post-PSVT diagnosis, tripling for patients <65 years ($9,028 to $29,867) and nearly doubling for patients ≥65 years ($10,867 to $20,143). Spending for PSVT services accounted for 43% and 33% of the increase in expenditures in these patient-groups, respectively. Few patients had an ablation within 1 year of diagnosis, although ablations were more frequent in patients age <65 years (13% vs 3%). In conclusion, PSVT imposes a substantial economic burden, with increases in expenditures following initial diagnosis in both younger (<65 years) and older (≥65 years) patients who are not accounted for by cardiac ablation spending alone.

A Long-Term Cost-Effectiveness Analysis Comparing Radiofrequency Catheter Ablation with Antiarrhythmic Drugs in Treatment of Chinese Patients with Atrial Fibrillation

INTRODUCTION

Radiofrequency catheter ablation (RFCA) is widely used to treat atrial fibrillation (AF) in China.

OBJECTIVE

We aimed to determine the long-term cost effectiveness of RFCA versus antiarrhythmic drugs (AADs) in treating AF from the perspective of third-party payers.

METHODS

The model was structured as a 12-month decision tree leading to a Markov model that simulated the follow-up treatment outcomes and costs with time horizons of 8, 15, and 20 years. Comparators were standard-of-care AADs. Clinical parameters captured normal sinus rhythm, AF, stroke, post-stroke, intracranial hemorrhage (ICH), gastrointestinal bleeding, post-ICH, and death. The risk of operative death, procedural complications, and adverse drug toxicity were also considered. The model output was quality-adjusted life-years (QALYs) and incremental cost per QALY gained.

RESULTS

RFCA incurred more costs than the AADs but resulted in more QALYs gained than did AADs. The incremental cost per QALY gained with RFCA versus AADs was ¥66,764, ¥36,280, and ¥29,359 at 8, 15, and 20 years, respectively. The sensitivity analyses showed that the results were most sensitive to the changes in RFCA cost and CHADS₂ score (clinical prediction rule for assessing the risk of stroke in patients with non-rheumatic AF).

CONCLUSION

Compared with AADs, RFCA significantly improves clinical outcomes and QALYs among patients with paroxysmal or persistent AF. From the Chinese payer's perspective, RFCA is a cost-effective therapy over long-term horizons.

Modelling the lifetime cost-effectiveness of catheter ablation for atrial fibrillation with heart failure

OBJECTIVES

Assessing the cost-effectiveness credentials of this intervention in patients with concomitant atrial fibrillation (AF) and heart failure (HF) compared with usual medical therapy.

DESIGN

A Markov model comprising two health states (ie, alive or dead) was constructed. The transition probabilities were directly derived from published Kaplan-Meier curves of the pivotal randomised controlled trial and extrapolated over the cohort's lifetime using recommended methods. Costs of catheter ablation, outpatient consultations, hospitalisation, medications and examinations were included. Resource use and unit costs were sourced from government websites or published literature. A lifetime horizon and a healthcare system perspective were taken. All costs and benefits were discounted at 3% annually. Deterministic (DSA) and probabilistic sensitivity analyses (PSA) were run around the key model parameters to test the robustness of the base case results.

PARTICIPANTS

A hypothetical Australian cohort of patients with concomitant AF and HF who are resistant to antiarrhythmic treatment.

INTERVENTIONS

Catheter ablation versus medical therapy.

RESULTS

The catheter ablation was associated with a cost of $A44 377 per person, in comparison to $A28 506 for the medical therapy alone over a lifetime. Catheter ablation contributed to 4.58 quality-adjusted life years (QALYs) and 6.99 LY gains compared with 4.30 QALYs and 6.53 LY gains, respectively, in the medical therapy arm. The incremental cost-effectiveness ratio was $A55 942/QALY or $A35 020/LY. The DSA showed that results were highly sensitive to costs of ablation and time horizon. The PSA yielded very consistent results with the base case.

CONCLUSIONS

Offering catheter ablation procedure to patients with systematic paroxysmal or persistent AF who failed to respond to antiarrhythmic drugs was associated with higher costs, greater benefits. When compared with medical therapy alone, this intervention is not cost-effective from an Australia healthcare system perspective.

Electrosurgical and Laser Therapy Tools for the Treatment of Malignant Central Airway Obstructions

Central airway obstruction (CAO) is associated with significant morbidity and increased mortality. Bronchoscopic electrosurgical and laser ablative tools have proven to be safe and effective instruments for the treatment of malignant CAO. Although therapeutic modalities such as electrocautery, argon plasma coagulation, and laser have been used for decades, additional tools including radiofrequency ablation catheters continue to be developed for the treatment of CAO. These modalities are considered safe in the hands of experienced operators, although serious complications can occur. This review describes various electrosurgical and laser therapy tools used for the treatment of malignant CAO along with the specific advantages and disadvantages of each device.

Cost-Effectiveness of Cryoballoon Ablation Versus Radiofrequency Ablation for Paroxysmal Atrial Fibrillation in China: Results Based on Real-World Data

BACKGROUND

Paroxysmal atrial fibrillation (AF) presents a significant economic burden to the healthcare system. Catheter ablations is a commonly adopted treatment for paroxysmal AF.

OBJECTIVES

To evaluate the cost effectiveness of cryoballoon ablation versus radiofrequency ablation in patients with drug-refractory paroxysmal AF in a tertiary hospital in China.

METHODS

A Markov model was developed to study the effects and costs. Cost and probability input data were obtained mainly from a retrospective real-world study conducted in a tertiary hospital. Propensity score matching was used to overcome retrospective bias. Input data gaps were remedied by means of literature review and advice from experts. A simulation was performed for the post-procedure lifetime years. Univariate and probabilistic sensitivity analyses were conducted.

RESULTS

In the base-case analysis of a lifetime time horizon, a patient treated with cryoballoon ablation was associated with 7.85 quality-adjusted life-years (QALYs) and ¥132 222 ($19 913) total costs, whereas a radiofrequency ablation treated patient was associated with 7.71 QALYs and ¥147 304 ($22 184) total costs. The cryoballoon group had slightly better health outcomes (with a difference of 0.14 QALY) and lower total costs (with a difference of ¥15 082) (USD $2 271), and it may be considered as cost-effective or cost-saving strategy (incremental cost-effectiveness ratio -¥110 158 [$16 590] per QALY) for the management of paroxysmal AF. Different scenarios were tested with sensitivity analyses, but still, the outcomes remained cost-effective or cost-saving for cryoballoon ablation.

CONCLUSIONS

An economic evaluation based on real-world data suggests that, relative to radiofrequency ablation, cryoballoon ablation may be considered as a more cost-effective or cost-saving long-term strategy for drug-refractory paroxysmal AF in this tertiary hospital in China. However, further evidence is needed using data from large-scale studies in order to reflect a national perspective.

Cost-reduction strategy for isoproterenol use in radiofrequency catheter ablation procedures

PURPOSE

A cost-reduction strategy for isoproterenol use in radiofrequency catheter ablation procedures was evaluated.

SUMMARY

A medication-use evaluation at a 454-bed tertiary medical center revealed that the cardiac catheterization laboratory was the highest user of isoproterenol. Isoproterenol was removed from all AcuDose-Rx machines Omnicell, Mountain View, CA, and compounding was performed by pharmacy personnel. It was initially provided to the cardiac catheterization laboratory as an 8-µg/mL concentration in 20-mL 0.9% sodium chloride injection syringes with a 24-hour beyond-use date. This resulted in an initial cost savings but with an unacceptably high rate of wastage. Isoproterenol was then compounded as a 4-µg/mL concentration in 30 mL 5% dextrose in water syringes with a 9-day beyond-use date after a thorough literature search supported longer stability with this admixture. After 12 months of our current process, isoproterenol use during radio frequency catheter ablations (RFCAs) in the cardiac catheterization laboratory was reduced by 85%, decreasing the number of ampules used from 11.15 to 1.66 per week.

CONCLUSION

A pharmacy-initiated process to mitigate an extraordinary increase in isoproterenol acquisition cost resulted in a reduction in usage in a tertiary care community hospital. Isoproterenol usage was reduced 85% after two different interventions were implemented, which is estimated to save $1,839 per procedure.

Cost-effectiveness analysis of a randomized clinical trial of early versus deferred endovenous ablation of superficial venous reflux in patients with venous ulceration

BACKGROUND

Treatment of superficial venous reflux in addition to compression therapy accelerates venous leg ulcer healing and reduces ulcer recurrence. The aim of this study was to evaluate the costs and cost-effectiveness of early versus delayed endovenous treatment of patients with venous leg ulcers.

METHODS

This was a within-trial cost-utility analysis with a 1-year time horizon using data from the EVRA (Early Venous Reflux Ablation) trial. The study compared early versus deferred endovenous ablation for superficial venous truncal reflux in patients with a venous leg ulcer. The outcome measure was the cost per quality-adjusted life-year (QALY) over 1 year. Sensitivity analyses were conducted with alternative methods of handling missing data, alternative preference weights for health-related quality of life, and per protocol.

RESULTS

After early intervention, the mean(s.e.m.) cost was higher (difference in cost per patient £163(318) (€184(358))) and early intervention was associated with more QALYs at 1 year (mean(s.e.m.) difference 0·041(0·017)). The incremental cost-effectiveness ratio (ICER) was £3976 (€4482) per QALY. There was an 89 per cent probability that early venous intervention is cost-effective at a threshold of £20 000 (€22 546)/QALY. Sensitivity analyses produced similar results, confirming that early treatment of superficial reflux is highly likely to be cost-effective.

CONCLUSION

Early treatment of superficial reflux is highly likely to be cost-effective in patients with venous leg ulcers over 1 year. Registration number: ISRCTN02335796 (http://www.isrctn.com).

Patient and facility variation in costs of catheter ablation for atrial fibrillation

BACKGROUND

Cost-effectiveness or value of cardiovascular therapies may be undermined by unwarranted cost variation, particularly for heterogeneous procedures such as catheter ablation for atrial fibrillation (AF). We sought to characterize cost variation of AF ablation in the US healthcare system and the relationship between cost and outcomes.

METHODS AND RESULTS

We performed a retrospective cohort study using data from the MarketScan® commercial claims and Medicare supplemental databases including patients who received an AF ablation from 2007 to 2011. We aggregated encounter cost, reflecting total payments received for the encounter, to the facility level to calculate median facility cost. We classified procedures as outpatient or inpatient and assessed for association between cost and 30-day and 1-year outcomes. The analysis cohort included 9,415 AF ablations (59±11 years; 28% female; 52% outpatient) occurring at 327 facilities, with large cost variation across facilities (median: $25,100; 25th percentile: $18,900, 75th percentile: $35,600, 95th percentile: $57,800). Among outpatient procedures, there was reduced healthcare utilization in higher cost quintiles with reductions in rehospitalization at 30-days (Quintile 1: 16.1%, Quintile 5: 8.8%, P < 0.001) and 1-year (Quintile 1: 34.8%, Quintile 5: 25.6%, P < 0.001), which remained significant in multivariate analysis.

CONCLUSIONS

Although median costs of AF ablation are below amounts used in prior cost-effectiveness studies that demonstrated good value, large facility variation in cost suggests opportunities for cost reduction. However, for outpatient encounters, association of cost to modestly improved outcomes suggests cost containment strategies could have variable effects.

Catheter radiofrequency ablation for arrhythmias under the guidance of the Carto 3 three-dimensional mapping system in an operating room without digital subtraction angiography

Several studies have reported the efficacy of a zero-fluoroscopy approach for catheter radiofrequency ablation of arrhythmias in a digital subtraction angiography (DSA) room. However, no reports are available on the ablation of arrhythmias in the absence of DSA in the operating room. To investigate the efficacy and safety of catheter radiofrequency ablation for arrhythmias under the guidance of a Carto 3 three-dimensional (3D) mapping system in an operating room without DSA. Patients were enrolled according to the type of arrhythmia. The Carto 3 mapping system was used to reconstruct heart models and guide the electrophysiologic examination, mapping, and ablation. The total procedure, reconstruction, electrophysiologic examination, and mapping times were recorded. Furthermore, immediate success rates and complications were also recorded. A total of 20 patients were enrolled, including 12 males. The average age was 51.3 ± 17.2 (19-76) years. Nine cases of atrioventricular nodal re-entrant tachycardia, 7 cases of frequent ventricular premature contractions, 3 cases of Wolff-Parkinson-White syndrome, and 1 case of typical atrial flutter were included. All arrhythmias were successfully ablated. The procedure time was 127.0 ± 21.0 (99-177) minutes, the reconstruction time was 6.5 ± 2.9 (3-14) minutes, the electrophysiologic study time was 10.4 ± 3.4 (6-20) minutes, and the mapping time was 11.7 ± 8.3 (3-36) minutes. No complications occurred. Radiofrequency ablation of arrhythmias without DSA is effective and feasible under the guidance of the Carto 3 mapping system. However, the electrophysiology physician must have sufficient experience, and related emergency measures must be present to ensure safety.

Use of the THERMOCOOL SMARTTOUCH catheter for ablation of atrial fibrillation: the relationship between hospital procedure volume, re-admissions, and economic outcomes

OBJECTIVE

The purpose of this study was to examine the relationship between hospital volume of prior THERMOCOOL SMARTTOUCH catheter use and health and economic outcomes among hospitalized patients with atrial fibrillation (AF) undergoing ablation using this device.

MATERIALS AND METHODS

Patients aged ≥18 years with a primary diagnosis of AF undergoing ablation treatment using the THERMOCOOL SMARTTOUCH catheter between January 2014 and June 2016 were identified from the Premier hospital database with the first date of such a procedure being defined as the index date. Hospital volume of prior THERMOCOOL SMARTTOUCH catheter use was determined during the 12-month pre-index period, and was classified into five groups: no volume (0), low volume (1-50), mid volume (51-100), high volume (101-150), and very high volume (≥151). Outcomes, including length of stay (LOS; for inpatient procedure only), hospital costs (total, hospital pharmacy, supply), and all-cause re-admission were evaluated. A generalized estimating equation (GEE) with exchangeable correlation structure was used to examine the impact of hospital volume on LOS, hospital costs, and re-admissions controlling for hospital clustering and other covariates.

RESULTS

The study population included 640 hospitalized AF patients. The adjusted mean LOS was significantly shorter in very high-volume hospitals than hospitals with no volume (mean LOS 2.30 vs 4.33 days; p = .0377). As volume increased, the mean adjusted supply cost tended to decrease, although these changes emerged as non-significant. The 12-month all-cause re-admission was significantly lower among patients undergoing ablation in low (Odds ratio [OR] = 0.27; confidence interval [CI] = 0.08-0.85) and mid (OR = 0.12; CI = 0.02-0.61) volume hospitals compared to hospitals with no volume.

LIMITATIONS

Study results may not be generalizable to all US hospitals.

CONCLUSIONS

Among AF patients undergoing ablation, increased hospital volume of prior THERMOCOOL SMARTTOUCH catheter use was associated with shorter LOS and a lower likelihood of all-cause re-admission.

Cost-effectiveness analysis of potentially curative and combination treatments for hepatocellular carcinoma with person-level data in a Canadian setting

Patients with early-stage hepatocellular carcinoma (HCC) are potential candidates for curative treatments such as radiofrequency ablation (RFA), surgical resection (SR), or liver transplantation (LT), which have demonstrated a significant survival benefit. We aimed to estimate the cost-effectiveness of curative and combination treatment strategies among patients diagnosed with HCC during 2002-2010. This study used Ontario Cancer Registry-linked administrative data to estimate effectiveness and costs (2013 USD) of the treatment strategies from the healthcare payer's perspective. Multiple imputation by logistic regression was used to handle missing data. A net benefit regression approach of baseline important covariates and propensity score adjustment were used to calculate incremental net benefit to generate incremental cost-effectiveness ratio (ICER) and uncertainty measures. Among 2,222 patients diagnosed with HCC, 10.5%, 14.1%, and 10.3% received RFA, SR, and LT monotherapy, respectively; 0.5-3.1% dual treatments; and 0.5% triple treatments. Compared with no treatment (53.2%), transarterial chemoembolization (TACE) + RFA (average $2,465, 95% CI: -$20,000-$36,600/quality-adjusted life years [QALY]) or RFA monotherapy ($15,553, 95% CI: $3,500-$28,500/QALY) appears to be the most cost-effective modality with lowest ICER value. The cost-effectiveness acceptability curve showed that if the relevant threshold was $50,000/QALY, RFA monotherapy and TACE+ RFA would have a cost-effectiveness probability of 100%. Strategies using LT delivered the most additional QALYs and became cost-effective at a threshold of $77,000/QALY. Our findings found that TACE+ RFA dual treatment or RFA monotherapy appears to be the most cost-effective curative treatment for patients with potential early stage of HCC in Ontario. These findings highlight the importance of identifying and measuring differential benefits, costs, and cost-effectiveness of alternative HCC curative treatments in order to evaluate whether they are providing good value for money in the real world.

The Impact of Cryoballoon Versus Radiofrequency Ablation for Paroxysmal Atrial Fibrillation on Healthcare Utilization and Costs: An Economic Analysis From the FIRE AND ICE Trial

BACKGROUND

This study sought to assess payer costs following cryoballoon or radiofrequency current (RFC) catheter ablation of paroxysmal atrial fibrillation in the randomized FIRE AND ICE trial.

METHODS AND RESULTS

A trial period analysis of healthcare costs evaluated the impact of ablation modality (cryoballoon versus RFC) on differences in resource use and associated payer costs. Analyses were based on repeat interventions, rehospitalizations, and cardioversions during the trial, with unit costs based on 3 national healthcare systems (Germany [€], the United Kingdom [£], and the United States [$]). Total payer costs were calculated by applying standard unit costs to hospital stays, using International Classification of Diseases, 10th Revision diagnoses and procedure codes that were mapped to country-specific diagnosis-related groups. Patients (N=750) randomized 1:1 to cryoballoon (n=374) or RFC (n=376) ablation were followed for a mean of 1.5 years. Resource use was lower in the cryoballoon than the RFC group (205 hospitalizations and/or interventions in 122 patients versus 268 events in 154 patients). The cost differences per patient in mean total payer costs during follow-up were €640, £364, and $925 in favor of cryoballoon ablation (P=0.012, 0.013, and 0.016, respectively). This resulted in trial period total cost savings of €245 000, £140 000, and $355 000.

CONCLUSIONS

When compared with RFC ablation, cryoballoon ablation was associated with a reduction in resource use and payer costs. In all 3 national healthcare systems analyzed, this reduction resulted in substantial trial period cost savings, primarily attributable to fewer repeat ablations and a reduction in cardiovascular rehospitalizations with cryoballoon ablation.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Identifier: NCT01490814.

Cost-effectiveness of Stereotactic Body Radiation Therapy versus Radiofrequency Ablation for Hepatocellular Carcinoma: A Markov Modeling Study

Purpose To assess the cost-effectiveness of stereotactic body radiation therapy (SBRT) versus radiofrequency ablation (RFA) for patients with inoperable localized hepatocellular carcinoma (HCC) who are eligible for both SBRT and RFA. Materials and Methods A decision-analytic Markov model was developed for patients with inoperable, localized HCC who were eligible for both RFA and SBRT to evaluate the cost-effectiveness of the following treatment strategies: (a) SBRT as initial treatment followed by SBRT for local progression (SBRT-SBRT), (b) RFA followed by RFA for local progression (RFA-RFA), (c) SBRT followed by RFA for local progression (SBRT-RFA), and (d) RFA followed by SBRT for local progression (RFA-SBRT). Probabilities of disease progression, treatment characteristics, and mortality were derived from published studies. Outcomes included health benefits expressed as discounted quality-adjusted life years (QALYs), costs in U.S. dollars, and cost-effectiveness expressed as an incremental cost-effectiveness ratio. Deterministic and probabilistic sensitivity analysis was performed to assess the robustness of the findings. Results In the base case, SBRT-SBRT yielded the most QALYs (1.565) and cost $197 557. RFA-SBRT yielded 1.558 QALYs and cost $193 288. SBRT-SBRT was not cost-effective, at $558 679 per QALY gained relative to RFA-SBRT. RFA-SBRT was the preferred strategy, because RFA-RFA and SBRT-RFA were less effective and more costly. In all evaluated scenarios, SBRT was preferred as salvage therapy for local progression after RFA. Probabilistic sensitivity analysis showed that at a willingness-to-pay threshold of $100 000 per QALY gained, RFA-SBRT was preferred in 65.8% of simulations. Conclusion SBRT for initial treatment of localized, inoperable HCC is not cost-effective. However, SBRT is the preferred salvage therapy for local progression after RFA. © RSNA, 2017 Online supplemental material is available for this article.

Cost comparison of radiofrequency catheter ablation versus cryoablation for atrial fibrillation in hospitals using both technologies

OBJECTIVE

The objective of this study was to compare the cost of radiofrequency (RF) ablation vs cryoablation (Cryo) for atrial fibrillation (AF).

METHODS

This retrospective cohort study used 2013-2014 records from the Premier Healthcare Database for adults with AF catheter ablation. Exclusions included non-AF ablation, surgical ablation, valve replacement or repair, or cardiac implant. Hospitals were required to perform ≥20 procedures using each technology, with the technology identifiable in at least 90% of cases. The primary endpoint was total variable visit cost, modeled separately for inpatient and outpatient visits, and adjusted for patient and hospital characteristics. Technology was categorized as RF or Cryo, with dual-technology procedures classified as Cryo. The Cryo cohort was further divided into Cryo only and Cryo with RF for sensitivity analyses. A composite adverse event endpoint was also compared.

RESULTS

A total of 1261 RF procedures and 1276 Cryo procedures, of which 500 also used RF, met study criteria. RF patients were slightly older and sicker, and had more cardiovascular disease and additional arrhythmias. Adjusted inpatient costs were $2803 (30.0%) higher for Cryo, and adjusted outpatient costs were $2215 (19.5%) higher. Sensitivity models showed higher costs in both Cryo sub-groups compared with RF. Procedural complication rates were not significantly different between cohorts (p-values: 0.4888 inpatient, 0.5072 outpatient).

CONCLUSION

AF ablation using RF results in significantly lower costs compared with Cryo, despite an RF population with more cardiovascular disease. This saving cannot be attributed to a difference in complication rates.