The Cost of Atrial Fibrillation: A Systematic Review

OBJECTIVES

Atrial fibrillation (AF) is the most common cardiac arrhythmia, with an increasing incidence and prevalence because of progressively aging populations. Costs related to AF are both direct and indirect. This systematic review aims to identify the main cost drivers of the illness, assess the potential economic impact resulting from changes in care strategies, and propose interventions where they are most needed.

METHODS

A systematic literature search of the PubMed and Scopus databases was performed to identify analytical observational studies defining the cost of illness in cases of AF. The search strategy was based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 recommendations.

RESULTS

Of the 944 articles retrieved, 24 met the inclusion criteria. These studies were conducted in several countries. All studies calculated the direct medical costs, whereas 8 of 24 studies assessed indirect costs. The median annual direct medical cost per patient, considering all studies, was €9409 (13 333 US dollars in purchasing power parities), with a very large variability due to the heterogeneity of different analyses. Hospitalization costs are generally the main cost drivers. Comorbidities and complications, such as stroke, considerably increase the average annual direct medical cost of AF.

CONCLUSIONS

In most of the analyzed studies, inpatient care cost represents the main component of the mean direct medical cost per patient. Stroke and heart failure are responsible for a large share of the total costs; therefore, implementing guidelines to manage comorbidities in AF is a necessary step to improve health and mitigate healthcare costs.

Potentially inappropriate prescribing and its demographic and clinical correlates in older adults with atrial fibrillation: a population-based study

Introduction

Older adults with atrial fibrillation (AF) have an increased risk of comorbidities and often take a combination of medicines. Moreover, it is known that anticoagulants tend to be underprescribed or underdosed in older patients with AF. Thus, it is important to evaluate the overall quality of prescribing because potentially inappropriate prescribing is associated with serious adverse events.

Purpose

To assess the quality of prescribing and to analyze the association between potentially inappropriate prescribing with demographic and clinical variables in a Swedish urban older population with AF.

Methodology

The Swedish National Study on Aging and Care is an observational longitudinal population-based study (baseline: 2001–2004) of adults aged 60 years or older (n=3363). We used the Screening Tool of Older Persons Prescriptions/Screening Tool to Alert doctors to Right Treatment (STOPP/START) version 2 algorithms (1) to assess the quality of prescribing. STOPP and START criteria identify potentially inappropriately prescribed medications and medications that are omitted but should have been prescribed, respectively. We could apply 72% of the STOPP criteria and 50% of the START criteria to the dataset. A hurdle negative binomial regression model was fitted to investigate the association between STOPP/START and age, sex, polypharmacy, and functional status indicated by activities of daily living.

Results

We analyzed data on 293 participants with AF. STOPP and START criteria occurred in 53.6% and 63.5% of older patients with AF, respectively. The most frequently inappropriately prescribed drugs (STOPP) were anticoagulants (4.8%), hypnotic Z-drugs (19.1%), benzodiazepines (19.1%) and drugs contributing to anticholinergic burden (6.8%). The most frequently omitted drugs (START) were antiplatelets (26%), anticoagulants (26%), statins (14.3%), beta-blockers (17.7%), vitamin D (15.7%), calcium supplements (15.7%) and laxatives (16%).

Polypharmacy (≥5 drugs; OR 3.45; 95% CI 1.85–6.44) was significantly associated with higher odds of having at least one STOPP criterion (Table 1). Disability (OR 2.56; 95% CI 1.26–5.21) was significantly associated with higher odds of having at least one START criterion.

Among persons with at least one STOPP or START criterion, the estimated mean number of STOPP and START criterion were 2.35 (95% CI 1.36–4.09) and 2.49 (95% CI 1.48–4.21) times higher, respectively, in persons with high polypharmacy (>10 drugs) compared to those without polypharmacy.

Conclusion

Potentially inappropriate prescribing and prescribing omissions were prevalent in this population of older adults with AF, beyond the well-known case of anticoagulants. Thorough multi-disciplinary medication reviews might improve quality of prescribing, especially in those with polypharmacy and functional impairment.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): This project has received funding from the European Union's Horizon 2020 research and innovation programme under grant agreement No. 899871.