Early Mortality After Catheter Ablation of Atrial Fibrillation

Excess Bed Days and Hospitalization Costs Associated With 30-Day Complications Following Catheter Ablation of Atrial Fibrillation

BACKGROUND

The incidence and type of complications following catheter ablation of atrial fibrillation have been extensively examined, but the impact associated with these complications on the length of stay and hospitalization costs is unknown.

METHODS AND RESULTS

This cohort study included 20 117 adult patients (mean age 62.6±11.4 years, 30.3% women, median length of stay 1 day [interquartile range 1-2 days]) undergoing atrial fibrillation ablation in financial years 2011 to 2017 in Australia with available cost data from the National Hospital Cost Data Collection, which determines government reimbursement of health services provided. The primary outcome was the costs associated with complications occurring up to 30 days postdischarge adjusted for inflation to 2021 Australian dollars. We used generalized linear models to estimate the increase in length of stay and cost associated with complications, adjusting for patient characteristics. Within 30 days of hospital discharge, 1151 (5.72%) patients experienced a complication with bleeding (3.35%) and pericardial effusion (0.75%) being the most common. On average, the occurrence of a complication was associated with an adjusted 3.3 (95% CI, 3.1-3.6) excess bed days of hospital care (totaling 3851 days), and a $7812 (95% CI, $6754-$8870) increase in hospitalization cost (totaling $9.0 million). Most of the total excess cost was attributable to bleeding ($3.8 million, 41.9% of total excess cost) and pericardial effusion ($1.6 million, 18.2%).

CONCLUSIONS

Complications following atrial fibrillation ablation were associated with significant increase in length of stay and hospitalization costs, most of which were attributable to bleeding and pericardial effusion. Strategies to improve procedural safety and reduce health care costs should focus on these complications.

Changing treatment landscape associated with improved survival in advanced hepatocellular carcinoma: a nationwide, population-based study

BACKGROUND AND AIMS

The treatment of hepatocellular carcinoma (HCC) is undergoing a historic transformation with the approval of several new systemic therapies in the last few years. This study aimed to examine the impact of this changing landscape on survival and costs in a Western nationwide, real-world cohort.

METHODS

A nationwide representative claims database (InGef) was screened for HCC cases between 2015 and 2020. Survival in an era with only sorafenib (period A, January 2015 to July 2018) and after approval of lenvatinib and other systemic treatments (period B, August 2018 to December 2020) was analysed. Health care costs were assessed.

RESULTS

We identified 2876 individuals with HCC in the study period. The proportion of patients receiving systemic therapy increased significantly over time, from 11.8% in 2015 to 15.1% in 2020 (p < 0.0001). The median overall survival in period B was 6.5 months (95% confidence interval [CI]: 4.9-8.9) and in period A was 5.3 months (95% CI: 4.5-6.3; p = 0.046). In period B, the median overall survival with lenvatinib was 9.7 months (95% CI: 6.3-18.4) versus 4.8 months with sorafenib (95% CI: 4.0-7.1, p = 0.008). Costs for prescription drugs per patient increased from €6150 in 2015 to €9049 in 2020 (p < 0.0001), and costs for outpatient care per patient increased from €1646 to €2149 (p = 0.0240).

CONCLUSION

The approval of new systemic therapies resulted in a survival benefit in patients with HCC. The magnitude of the effect is modest and associated with a moderate increase in health costs.

Ten-year trends in mortality and complications following catheter ablation of atrial fibrillation

AIMS

Recent US studies report rising rates of mortality and in-hospital complications following catheter ablation of atrial fibrillation (AF), but whether this is a global phenomenon is uncertain. The aim of this study was to examine trends in 30-day mortality and complications following AF ablation in Australia and New Zealand (ANZ) from 2008 to 2017.

METHODS AND RESULTS

We identified 37 243 AF (mean age 62.4 ± 11.5 years, 29.6% females, 94.5% elective procedures) ablations using national hospitalization data. The primary outcome was occurrence of any complication, including all-cause mortality, within 30 days of discharge. Trends were evaluated using logistic regression adjusting for changes in patient characteristics. The annual number of ablations increased from 1359 (2008) to 5115 (2017). Patients' age and rates of heart failure (9.8-10.6%), diabetes (6.8-12.4%), and chronic kidney disease (2.2-4.1%) also increased over time. From 2008 to 2017, the overall rate of complications declined from 7.51% to 5.04% [adjusted odds ratio (aOR) 0.96 (95% confidence interval, CI, 0.94-0.97)/year]. Rates of pericardial effusion [1.69-0.70%, aOR 0.93 (0.89-0.97)], bleeding [4.49-2.74%, aOR 0.94 (0.92-0.96)], and vascular injury [0.52-0.16%, aOR 0.91 (0.85-0.98)] declined, but rates of acute kidney injury [0.15-0.68%, aOR 1.16 (1.08-1.25)] and infection [0.15-0.57%, aOR 1.07 (1.01-1.14)] increased over time. The overall 30-day mortality rate was low (0.11%) and unchanged [0.00-0.16%, aOR 0.99 (0.88-1.11)].

CONCLUSION

Despite a five-fold increase in AF ablations and the rising risk profile of patients, complications following AF ablation declined by 30% from 2008 to 2017 in ANZ. Procedure-related death was uncommon and occurred in less than 1 in 850 patients.

Institutional Variation in 30‐Day Complications Following Catheter Ablation of Atrial Fibrillation

Background

Complications are a measure of procedural quality, yet variation in complication rates following catheter ablation of atrial fibrillation (AF) among hospitals has not been systematically examined. We examined institutional variation in the risk‐standardized 30‐day complication rates (RSCRs) following AF ablation which may suggest variation in care quality.

Methods and Results

This cohort study included all patients >18 years old undergoing AF ablations from 2012 to 2017 in Australia and New Zealand. The primary outcome was procedure‐related complications occurring during the hospital stay and within 30 days of hospital discharge. We estimated the hospital‐specific risk‐standardized complication rates using a hierarchical generalized linear model. A total of 25 237 patients (mean age, 62.5±11.4 years; 30.2% women; median length of stay 1 day [interquartile range, 1–2 days]) were included. Overall, a complication occurred in 1400 (5.55%) patients (4.34% in hospital, 1.46% following discharge, and 0.25% experienced both). Bleeding (3.31%), pericardial effusion (0.74%), and infection (0.44%) were the most common complications while stroke/transient ischemic attack (0.24%), cardiorespiratory failure and shock (0.19%), and death (0.08%) occurred less frequently. Among 46 hospitals that performed ≥25 ablations during the study period, the crude complication rate varied from 0.00% to 21.43% (median, 5.74%). After adjustment for differences in patient and procedural characteristics, the median risk‐standardized complication rate was 5.50% (range, 2.89%–10.31%), with 10 hospitals being significantly different from the national average.

Conclusions

Procedure‐related complications occur in 5.55% of patients undergoing AF ablations, although the risk of complications varies 3‐fold among hospitals, which suggests potential disparities in care quality and the need for efforts to standardize AF ablation practices among hospitals.

GENDER DIFFERENCES IN COMPLICATIONS FOLLOWING CATHETER ABLATION OF ATRIAL FIBRILLATION

AIM

Population studies that provide unbiased estimates of gender differences in risk of complications following catheter ablation of atrial fibrillation (AF) are sparse. We sought to evaluate the association of female gender and risk of complications following AF ablation in a nation-wide cohort.

METHODS AND RESULTS

We identified 35,211 patients (29.5% females) undergoing AF ablations from 2008-17 using national hospitalization data from Australia and New Zealand. The primary outcome was any procedural complication occurring up to 30-days after discharge. Logistic regression was used to adjust for differences in baseline characteristics between sexes. Compared with males, females were older (mean age 64.9 vs. 61.2 years), had higher rates of hypertension (14.0% vs. 11.6%) and hematological disorders (5.3% vs. 3.8%) and experienced a higher rate of procedural complications (6.96% vs. 5.41%) (all p<0.001). This gender disparity remained significant after adjustment (OR 1.25 [95%CI 1.14-1.38], p<0.001) and was driven by an increased risk of vascular injury (OR 1.86 [1.23-2.82], p=0.003), pericarditis (OR 1.86 [1.16-2.67], p=0.008), pericardial effusion (OR 1.71 [1.35-2.17], p< 0.001), and bleeding (OR 1.30 [1.15-1.46], p<0.001). Notably, the gender difference persisted over time (OR for the most recent period 1.19 [1.003-1.422], p=0.046) despite a declining complication rate in both men and women.

CONCLUSION

Females undergoing AF ablations experienced a 25% higher risk of procedural complications compared with males, a disparity that has persisted over time despite a falling complication rate. Efforts to reduce this gender disparity should focus on reducing the incidence of pericardial effusion, pericarditis, vascular injury, and bleeding.