Surgical treatments for men with benign prostatic enlargement: cost effectiveness study

OBJECTIVE

To determine which surgical treatment for lower urinary tract symptoms suggestive of benign prostate enlargement is cost effective.

DESIGN

Care pathways describing credible treatment strategies were decided by consensus. Cost-utility analysis used Markov modelling and Monte Carlo simulation.

DATA SOURCES

Clinical effectiveness data came from a systematic review and an individual level dataset. Utility values came from previous economic evaluations. Costs were calculated from National Health Service (NHS) and commercial sources.

METHODS

The Markov model included parameters with associated measures of uncertainty describing health states between which individuals might move at three monthly intervals over 10 years. Successive annual cohorts of 25,000 men were entered into the model and the probability that treatment strategies were cost effective was assessed with Monte Carlo simulation with 10,000 iterations.

RESULTS

A treatment strategy of initial diathermy vaporisation of the prostate followed by endoscopic holmium laser enucleation of the prostate in case of failure to benefit or subsequent relapse had an 85% probability of being cost effective at a willingness to pay value of pound20,000 (euro21,595, $28,686)/quality adjusted life year (QALY) gained. Other strategies with diathermy vaporisation as the initial treatment were generally cheaper and more effective than the current standard of transurethral resection repeated once if necessary. The use of potassium titanyl phosphate laser vaporisation incurred higher costs and was less effective than transurethral resection, and strategies involving initial minimally invasive treatment with microwave thermotherapy were not cost effective. Findings were unchanged by wide ranging sensitivity analyses.

CONCLUSION

The outcome of this economic model should be interpreted cautiously because of the limitations of the data used. The finding that initial vaporisation followed by holmium laser enucleation for failure or relapse might be advantageous both to men with lower urinary tract symptoms and to healthcare providers requires confirmation in a good quality prospective clinical trial before any change in current practice. Potassium titanyl phosphate laser vaporisation was unlikely to be cost effective in our model, which argues against its unrestricted use until further evidence of effectiveness and cost reduction is obtained.

Time and cost savings in arthroscopic subacromial decompression: the use of bipolar versus monopolar radiofrequency

There is currently an increased interest in the use of electro surgery in arthroscopy. Since the introduction of the bipolar arthroscopic radiofrequency (RF) wand, it has started to replace the classic Bovie monopolar probe on the assumption that the new technology provides multifunctional devices, combining both tissue removal and haemostasis into one instrument. The more efficient tissue ablation and precise haemostasis achieved with these instruments should result in a significant reduction in the operative time and cost. We ran a prospective comparative randomised study to test this hypothesis. Forty patients underwent arthroscopic subacromial decompression, randomised into two groups. The group treated with bipolar RF was associated with an average operative time saving of 8 min (P < 0.0001) and an average cost saving of pound 83 (euro 111) per case (P < 0.003), compared to monopolar RF. Bipolar RF is the instrument of choice in arthroscopic shoulder surgery, as it saves time and money.

[Percutaneous, laparoscopic and open surgical radiofrequency ablation of malignant liver lesions]

The growing clinical impact of radiofrequency ablation of liver lesions is reflected by a rapidly increasing number of published papers. Experimental work focuses on factors that reduce the variability of the ablation zone. The Pringle-maneuver plays a key role in this question from a surgeon's perspective. Large single center studies and a meta-analysis show a sharp rise in the rate of local recurrences for tumors larger 3 cm. An open surgical approach is significantly correlated to a low local recurrence rate. Bile duct lesions and intrahepatic abscesses are the most frequent complications. Intraductal bile duct cooling can prevent these complications. Three prospective randomized trials support the use of RFA for small hepatocellular carcinoma. The use of RFA in patients with multiple colorectal metastases is supported by single center studies showing a 3 year survival of > 35%. The favourable cost / benefit ratio will make RFA a part of future multimodal cancer therapy concepts.

A health economic evaluation of concomitant surgical ablation for atrial fibrillation

OBJECTIVE

Current drug treatment for atrial fibrillation is suboptimal and percutaneous catheter-based ablation techniques may be associated with complications. The aim of this study is to assess the cost-effectiveness of (1) high-intensity focused ultrasound (HIFU)-assisted surgical ablation, (2) the classic 'cut and sew' maze procedure and (3) percutaneous ablation, all concomitant to cardiac surgery (e.g. CABG, valve repair) in comparison with non-interventional (drug) treatment.

METHODS

A Markov model was developed to predict the cost-effectiveness of the interventional approaches. The model consisted of four disease states (sinus rhythm without complications, atrial fibrillation without complications, stroke and death), allowing for 3-monthly transitions between these states and using direct UK costs from the National Health Service perspective. Clinical input data are obtained from literature and cost input data from National Health Service sources and literature. Five-year total and incremental costs are calculated. Incremental effects are expressed in quality-adjusted-life-years-gained (QALYG).

RESULTS

All interventional treatments show good incremental cost-effectiveness ratios in all atrial fibrillation types, compared to drug treatment. For classic maze the incremental cost-effectiveness ratio compared to non-interventional atrial fibrillation treatment varies from 1343 to 3471 GBP/QALYG, for HIFU-assisted surgical ablation from 4005 to 7448 GBP/QALYG and for percutaneous ablation from 7041 to 17,372 GBP/QALYG depending on the atrial fibrillation type. Sensitivity analyses showed the robustness of the data.

CONCLUSIONS

Performing a classic maze procedure or HIFU-assisted surgical ablation concomitant to a scheduled CABG or valve procedure is highly cost-effective. Performing a percutaneous ablation in a subsequent procedure is also cost-effective, but to a lower extent. Both the maze procedure and the HIFU-assisted surgical ablation are cheaper and more effective than percutaneous ablation in a subsequent procedure.

[Alprazolam use improves psychological status and reduces hospitalization costs in patients with paroxysmal supraventricular tachycardia underwent radiofrequency catheter ablation]

OBJECTIVE

To evaluate the effect of alprazolam use on psychological status and hospitalization cost in patient with paroxysmal supraventricular tachycardia underwent electrophysiology studies or radiofrequency catheter ablation.

METHODS

In this prospective, randomized, double-blind, placebo-controlled study, 142 inpatients [77 males, mean age (43.1 +/- 14.5) years] were randomly assigned to receive alprazolam (0.4 mg qd at 10PM for 3 days, n = 72) or placebo (n = 70) 3 days before scheduled electrophysiology studies or radiofrequency catheter ablation. All patients were examined by the Chinese version of Symptom Checklist-90 (SCL-90) at 24 hours before the procedure.

RESULTS

Compared with the placebo group, the scores of somatization (1.38 +/- 0.40 vs. 1.65 +/- 0.56, P < 0.01), anxiety (1.50 +/- 0.39 vs. 1.69 +/- 0.50, P < 0.05), phobic anxiety (1.24 +/- 0.36 vs. 1.47 +/- 0.57, P < 0.01), psychotism constructs (1.24 +/- 0.34 vs. 1.35 +/- 0.30, P < 0.05) and global severity index (1.36 +/- 0.35 vs. 1.49 +/- 0.37, P < 0.05) were significantly decreased in alprazolam group. The hospitalization costs were also significantly lower in alprazolam group (32 498 +/- 1170) yuan compared to placebo group (32 947 +/- 1096) yuan, P < 0.05.

CONCLUSION

The alprazolam use before electrophysiology studies and radiofrequency catheter ablation can improve the patients' psychological status and reduce the hospitalization costs.

Intraoperative Cryoablation of Atrial Fibrillation With the Old-Fashioned Cryode Tips: A Simple, Effective, and Inexpensive Method

Nowadays atrial fibrillation is usually treated simultaneously with cardiac procedures, and new cryo-systems have been developed for performing easier and faster intraoperative ablation. However, the old cryode designs can still be useful in surgical practice and represent a more cost-effective method. In this article we present a technique using old-fashioned cryodes for intraoperative treatment of atrial fibrillation and comment on its advantages and limitations.

Cost Comparison of Catheter Ablation and Medical Therapy in Atrial Fibrillation

INTRODUCTION

There is emerging evidence for clinical superiority of catheter ablation over rate and rhythm control strategies in paroxysmal atrial fibrillation (PAF). The objective of this study was to compare costs related to medical therapy versus catheter ablation for PAF in Ontario (Canada).

METHODS

Costs related to medical therapy in the analysis included the cost of anticoagulation, rate and rhythm control medications, noninvasive 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, and costs related to periprocedural medical care and complications. Costs related to these various elements were obtained from the Canadian Registry of Atrial Fibrillation (CARAF), government fee schedules, and published data. Sensitivity analyses looking at a range of initial success rates (50-75%) and late attrition rates (1-5%), prevalence of congestive heart failure (CHF) (20-60%), as well as discounting varying from 3% to 5% per year were performed.

RESULTS

The cost of catheter ablation ranged from $16,278 to $21,294, with an annual cost of $1,597 to $2,132. The annual cost of medical therapy ranged from $4,176 to $5,060. Costs of ongoing medical therapy and catheter ablation for PAF equalized at 3.2-8.4 years of follow-up.

CONCLUSION

Catheter ablation is a fiscally sensible alternative to medical therapy in PAF with cost equivalence after 4 years.

Radiofrequency minimally invasive endovascular treatment of lower limbs varicose veins: clinical experience and literature review

AIM

Varicose veins of the legs are a common condition affecting 10-15% of men and 20-25% of women in the western world. This high prevalence is responsible of high medical and social costs. Most primary varices are associated with greater saphenous vein (GSV) incompetence. A new method, radiofrequency (RF) endovenous obliteration (VNUS-Closure'' procedure), recently has been described as a less invasive and cost-saving alternative to stripping for the treatment of refluxing GSV.

METHODS

Twenty-four patients with varicose veins underwent endovenous obliteration of the above knee GSV by VNUS Closure'' procedure. The vein diameters were from 5 to 10 mm. The RF catheter was inserted via percutaneous puncture or through a small skin incision. All operations were performed in local, tumescent anesthesia, under ultrasound guidance. All patients were discharged 2 h after operation. Clinical and ultrasound follow-up was performed at 1 week, and at 1, 6, 12, 24 months.

RESULTS

The complete or partial occlusion of the treated segment of the GSV has been achieved in 23 cases. In only one patient persisting patency of the GSV was immediately detected after the procedure. That was successfully treated by ultrasound guided foam sclerotherapy. All patients could resume all normal activities within 3-5 days. Every patient had reduction of varicosities, leg pain, fatigue and oedema. Adverse sequelae were minimal: 2 patients had transient thigh paresthesias. We didn't report deep venous thrombosis or pulmonary embolism (mean follow-up 26.7 months, range 15-33 months).

CONCLUSION

A literature review and the authors'experience reveal that, in absence of significant complications, such as deep vein thrombosis and pulmonary embolism, there are significant advantages in the RF endovascular obliteration of the GSV. In effect, the Closure'' procedure, in selected patients, offers reduced postoperative pain, shorter sick leaves, faster return to normal activities compared with vein stripping, and it appears to be cost-saving for society. The mid-term (36 months) recurrence rates after RF obliteration seem to be similar to the results of the conventional surgical management.

Cost-utility of levonorgestrel intrauterine system compared with hysterectomy and second generation endometrial ablative techniques in managing patients with menorrhagia in the UK

OBJECTIVE

To estimate the cost-utility of levonorgestrel intrauterine system (LNG-IUS; Mirena) compared to second generation endometrial ablative techniques [i.e. microwave endometrial ablation (MEA) and thermal balloon endometrial ablation (TBEA)) and hysterectomy in the UK.

METHODS

Clinical and utility data from a 5-year randomised controlled trial comparing LNG-IUS with hysterectomy were combined with further data from published studies to construct a state-transition (Markov) model. The model depicted the movement of patients between health states over 5 years following treatment for menorrhagia. The model was used to estimate the cost-utility of LNG-IUS followed by ablation (L-A); LNG-IUS followed by hysterectomy (L-H); immediate ablation (MEA or TBEA) and immediate hysterectomy in the UK at 2004/2005 prices, from the perspective of the UK's National Health Service (NHS).

MAIN OUTCOME MEASURES AND RESULTS

The expected 5-yearly cost of treating menorrhagia with L-A, L-H, TBEA, MEA and hysterectomy was estimated to be 828 pounds sterling, 1355 pounds sterling, 1679 pounds sterling, 1812 pounds sterling and 2983 pounds sterling per patient respectively and the expected level of health gain to be 4.14, 4.12, 4.13, 4.13 and 4.01 QALYs per patient respectively. LNG-IUS followed by ablation dominated all the alternative treatments. Hysterectomy was dominated by the alternative treatments. Sensitivity analysis found the model to be sensitive to the quality of life data used.

CONCLUSION

Within the model's limitations, LNGIUS followed by ablation appears to offer the NHS a cost-effective treatment for menorrhagia, when compared to immediate surgery, affording the NHS a less expensive treatment modality without detrimental effects on resulting health gain.

Catheter ablation as first-line therapy for patients with symptomatic atrial fibrillation

Atrial fibrillation (AF) is a common clinical problem that is associated with an impaired quality of life, thromboembolism, heart failure and death. Medical treatment of AF remains suboptimal and is associated with potentially serious side effects. The disappointing outcomes with medical therapy have spurred the age of catheter ablation of AF. In the last 10 years, catheter ablation of AF has evolved dramatically and has been shown to be superior to medical therapy in multiple studies. As a result, catheter ablation may be offered to the symptomatic patient as first-line therapy in lieu of antiarrhythmic medications, which have limited efficacy and are associated with significant toxicity.

The impact of reimbursement on the usage of pacemakers, implantable cardioverter defibrillators and radiofrequency ablation

An international questionnaire survey was carried out in Asia Pacific, Europe, Latin America and North America to assess the impact of reimbursement on the indications, types of device prescription and waiting time for pacemakers, implantable cardioverter defibrillators (ICD) and radiofrequency ablation therapy for cardiac arrhythmias. The indications for cardiac pacing can be restricted to more symptomatic patients when funding is limited, and new therapy such as cardiac resynchronization therapy (CRT) is restricted in many regions. ICD usage may be limited to secondary prevention candidates because of reimbursement, but referral doctor's ambivalence and knowledge are also important issues independent of the types of health care system. Radiofrequency ablation is generally well accepted, but reimbursement is heterogeneous, with non-fluoroscopic mapping being reimbursed only in a limited way worldwide. Thus with the exception of a well-developed health care system, reimbursement has a major impact on the delivery of arrhythmia management devices and procedures worldwide.

A clinical and health-economic evaluation of pulmonary vein encircling ablation compared with antiarrhythmic drug treatment in patients with persistent atrial fibrillation (Catheter Ablation for the Cure of Atrial Fibrillation-2 study)

AIMS

Catheter Ablation for the Cure of Atrial Fibrillation 2 study is a prospective, randomized trial aimed to demonstrate the efficacy of catheter ablation with combined lesions in the right and left atria, in preventing atrial fibrillation (AF) recurrences among patients with recurrent persistent AF refractory to one antiarrhythmic drug, in comparison with the best pharmacological therapy.

METHODS AND RESULTS

Enrolment is limited to patients aged between 18 and 70 years who have experienced at least one documented relapse of persistent AF during antiarrhythmic drug therapy. One hundred and twenty-six patients will be randomized to ablation or antiarrhythmic drug therapy in a 2 : 1 manner. In the ablation group, the patients will undergo right and left atrial linear ablation. Control group patients will be treated with the best antiarrhythmic drug. After an initial blanking period of 2 months patients will be followed for 24 months. Primary endpoint of the study is the absence of documented persistent atrial tachyarrhythmias relapse during the first 24 months after the blanking period. Enrolment is scheduled in 14 centres in Italy, UK, Austria, and Finland. Seventy-two patients have currently been enrolled.

CONCLUSION

This study will provide important data about the efficacy of catheter ablation in comparison with antiarrhythmic drugs for the treatment of persistent AF.

Ethanol versus radiofrequency ablation for the treatment of small hepatocellular carcinoma in patients with cirrhosis: a retrospective study of efficacy and cost

OBJECTIVE

To compare cost effectiveness of radio-frequency (RF) ablation versus percutaneous ethanol (Pe) ablation for treatment of small hepatocellular carcinoma.

METHODS

57 patients with 72 hepatocellular carcinomas (HCC) treated with ethanol ablation were retrospectively compared with 60 new patients who had 72 HCC treated with RF ablation. All patients had Child-Pugh A cirrhosis and HCC less than 3.5 cm in diameter. Therapeutic efficacy was evaluated with tri-phase spiral computed tomography. Cost of hospital stay, supplies and follow-up including complications were calculated. Survival was estimated by Kaplan-Meier method and prognostic value of treatment methods by Log Rank test and multivariate Cox proportional hazard model.

RESULTS

The two groups had similar baseline characteristics. The rate of severe complications associated with RF was 15% (9/60) vs 6,9% (9/60) with Pe (P=0,11) The two-year overall survival, disease free survival and local tumor free survival in the ethanol and radiofrequency groups were 70.8% vs. 91.2% (Odd Ratio=3.7, P=0.006), 48.6% vs. 71.1% (Odd Ratio=2.2, P=0.01), and 68.5% vs. 80.7%, (Odd Ratio=1.9; P=0.09), respectively. The treatment method was the sole significant factor related to overall and tumor free survival. Costs per patient of ethanol and radiofrequency treatments were 1534 euro and 1196 euro, respectively.

CONCLUSION

This retrospective study suggests that RF is the most cost effective strategy, with higher 2-year disease free survival rate.

Cost-effectiveness of catheter ablation for atrial fibrillation

PURPOSE OF REVIEW

Catheter ablation for atrial fibrillation is a rapidly evolving field. It has been adopted at many institutions worldwide. This review compares the efficacy and cost of catheter ablation and medical therapy in atrial fibrillation patients.

RECENT FINDINGS

There is emerging evidence for clinical superiority of catheter ablation over medical therapy for restoring and maintaining sinus rhythm in atrial fibrillation patients. Early analyses of costs related to catheter ablation in atrial fibrillation suggest that medical therapy and catheter ablation become cost-equivalent at about 5 years of follow-up. A recent cost-effectiveness study concluded that catheter ablation is a cost-effective alternative to medical care in younger and older patients at low and moderate risk of stroke, assuming that restoration and maintenance of sinus rhythm with ablation would have some protective effect with respect to embolic events.

SUMMARY

Catheter ablation is a potentially cost-effective strategy in select patients with atrial fibrillation. Long-term randomized studies that compare it to conventional care and focus on outcomes of morbidity and mortality are necessary prior to widespread application of this technique.

Managing drug-resistant essential menorrhagia without hysterectomy

Menorrhagia is a common disorder that requires plenty of resources. Rapid developments in medical technology have resulted in new management strategies, which are true alternatives to hysterectomy. In many countries the levonorgestrel-releasing intrauterine system (LNG-IUS) and endometrial destruction techniques are available for menorrhagia. Clinicians must answer questions about cost, effectiveness and quality of medical care when choosing the treatment option. This review integrates the results from the latest studies and review articles about LNG-IUS and endometrial destruction techniques by addressing the key clinical issues in menorrhagia. Both LNG-IUS and endometrial ablation seem to be good and effective alternative options to hysterectomy. Although these treatments have relatively high failure rates, the majority of women are satisfied and the cost-effectiveness of these treatments are better than that of hysterectomy. Both treatments have their advantages and disadvantages. Thus far LNG-IUS seems to be more cost-effective than endometrial resection or hysterectomy at 5 years follow-up. However, second generation ablation techniques may offer better cost-effectiveness than the first generation techniques, but the evidence is insufficient.

Quality of life and cost for patients with premature ventricular contractions by radiofrequency catheter ablation

OBJECTIVE

To evaluate the quality of life (QoL), health-care resource utilization, and cost for the patients with premature ventricular contractions (PVCs) by radiofrequency catheter ablation (RFCA).

METHODS

RFCA was performed in 58 patients with symptomatic PVCs that were refractory/easy to medication. A 24-hour ambulatory electrocardiographic monitoring, QoL, health-care resources utilization, and cost were assessed at a screening visit and 3 and 12 months after RFCA.

RESULTS

RFCA was successfully performed in 56 patients (96.6%). This resulted in a significant improvement in the QoL at 3 and 12 months after the procedure. There were no major complications related to the procedure. Nine patients (15.5%) had residual arrhythmia. Seven of them underwent repeated ablation with successful results. It also improved the QoL and reduced health-care resource utilization and cost.

CONCLUSIONS

RFCA is a safe and effective treatment for PVCs, and it is a viable alternative to drugs in the presence of disabling symptoms.

Radiofrequency catheter ablation of supraventricular tachycardia in children and adolescents : feasibility and cost-effectiveness in a low-income country

The objective of this study is to provide results and costs of catheter ablation in children and adolescents in a low-income country. Reports from first-world countries have demonstrated the cost-effectiveness of radiofrequency catheter ablation (RFCA) compared to medical treatment of supraventricular tachycardia (SVT). The study included 28 patients younger than 18 years of age with SVT in a pediatric cardiology unit in Guatemala. All patients underwent RFCA. Clinical outcome and cost-effectiveness of RFCA compared to continued medical treatment were the end points. Twenty-four patients had successful ablation (85.7%). Mean age at RFCA was 11.42 +/- 3.49 years. Three patients underwent a second ablation, increasing the success rate to 96.4%. One remaining patient is awaiting a second procedure. At a mean follow-up of 13.69 +/- 7.16 months, all 27 patients who had a successful ablation remained in sinus rhythm. Mean cost per procedure was 4.9 times higher than that of medical treatment. However, the estimated cost of catheter ablation equal that of medical therapy after 5.1 years and is 3.4 times less after 20 years. Radiofrequency catheter ablation of SVT in children and adolescents is safe and cost-effective compared to medical therapy. Resources must be judiciously allocated, especially in low-income countries, to treat the largest number of pediatric patients.

Cost-effectiveness of treatments for dysfunctional uterine bleeding

OBJECTIVE

To compare the cost-effectiveness of treatments for dysfunctional uterine bleeding (DUB).

STUDY DESIGN

The decision analytic model used a third-party payer perspective and 18-month horizon to compare treatment of DUB patients > or = 40 years old with no desire for fertility. Treatments were oral contraceptives (OCs) vs. surgery (first-/second-generation ablation or hysterectomy) after 3-9 months of OCs. Costs were based on publications and expert opinion. Efficacy measures were based on months with pictorial blood loss assessment chart (PBAC) score < 100 and number of months of amenorrhea.

RESULTS

Treatment costs were estimated at 513 dollars per patient per year (OCs), 3,500 dollars (first-generation ablation), 3,000 dollars (second-generation ablation) and 7,500 dollars (hysterectomy). Adverse event costs ranged from 12 dollars per year or episode (OCs, second-generation ablation) to 164 dollars per episode (hysterectomy). To achieve PBAC < 100, second-generation ablation after 3 months of OCs was the most cost-effective (7.6 additional DUB-free months vs. OCs, 215 dollars per additional month). Second-generation ablation was less costly and more effective than first-generation ablation. Early treatment with hysterectomy was more effective than ablation, but at substantial cost. When using the end point of amenorrhea, hysterectomy was most cost-effective. Results were not sensitive to variations in costs, effectiveness or length of OC use.

CONCLUSION

A short OC trial followed by second-generation ablation is the most cost-effective strategy for women with DUB, although hysterectomy is more cost-effective to achieve amenorrhea. Hysterectomy cost-effectiveness might improve if evaluated over more time. Cost-effectiveness and patient preference must all play a role in treatment decisions.

Cost-effectiveness of radiofrequency catheter ablation for atrial fibrillation

OBJECTIVES

We sought to compare the cost-effectiveness of left atrial catheter ablation (LACA), amiodarone, and rate control therapy in the management of atrial fibrillation (AF).

BACKGROUND

Left atrial catheter ablation has been performed to eliminate AF, but its cost-effectiveness is unknown.

METHODS

We developed a decision-analytic model to evaluate the cost-effectiveness of LACA in 55- and 65-year-old cohorts with AF at moderate and low stroke risk. Costs, health utilities, and transition probabilities were derived from published literature and Medicare data. We performed primary threshold analyses to determine the minimum level of LACA efficacy and stroke risk reduction needed to make LACA cost-effective at 50,000 dollars and 100,000 dollars per quality-adjusted life-year (QALY) thresholds.

RESULTS

In 65-year-old subjects with AF at moderate stroke risk, relative reduction in stroke risk with an 80% LACA efficacy rate for sinus rhythm restoration would need to be > or =42% and > or =11% to yield incremental cost-effectiveness ratios (ICERs) <50,000 dollars and 100,000 dollars per QALY, respectively. Higher and lower LACA efficacy rates would require correspondingly lower and higher stroke risk reduction for equivalent ICER thresholds. In the 55-year-old moderate stroke risk cohort, lower LACA efficacy rates or stroke risk reduction would be needed for the same ICER thresholds. In patients at low stroke risk, LACA was unlikely to be cost-effective.

CONCLUSIONS

The use of LACA may be cost-effective in patients with AF at moderate risk for stroke, but it is not cost-effective in low-risk patients. Our threshold analyses may provide a framework for the design of future clinical trials by providing effect size estimates for LACA efficacy needed.