Cost-effectiveness of screening for paroxysmal atrial fibrillation in patients undergoing echocardiography.
atrial fibrillation
cost-effectiveness
echocardiography
screening
Journal
Internal medicine journal
ISSN: 1445-5994
Titre abrégé: Intern Med J
Pays: Australia
ID NLM: 101092952
Informations de publication
Date de publication:
05 2023
05 2023
Historique:
revised:
14
01
2022
received:
17
07
2021
accepted:
29
03
2022
medline:
25
5
2023
pubmed:
5
4
2022
entrez:
4
4
2022
Statut:
ppublish
Résumé
Screening for atrial fibrillation is recommended for patients > 65 years on current guidelines. Targeted screening may be more efficient, however the appropriate location for screening programs has not been well defined. Our aim was to compare the cost-effectiveness of unselected electrocardiographic (ECG) screening for atrial fibrillation (AF), and selective screening based on an abnormal echocardiogram. Two strategies of portable ECG screening for AF were compared in the base case of a hypothetical asymptomatic 65-year-old man (CHA ImagingScreen dominated AgeScreen, with a lower cost ($54 823 vs $57842) and better outcome (11.56 vs 11.52 QALY over 20 years). Monte Carlo simulation demonstrated that 61% of observations were more efficacious with ImagingScreen, with cost below willingness to pay. The main cost determinants were annual costs of stroke or heart failure and AF detection rates. ImagingScreen was more cost-effective for AF detection rates up to 14%, and more cost-effective across a range of annual stroke ($24 000-$102 000) and heart failure ($4000-$12 000) costs. In patients with a previous echocardiogram, AF screening of those with baseline clinical and imaging risk parameters is more cost-effective than age-based screening.
Sections du résumé
BACKGROUND
Screening for atrial fibrillation is recommended for patients > 65 years on current guidelines. Targeted screening may be more efficient, however the appropriate location for screening programs has not been well defined. Our aim was to compare the cost-effectiveness of unselected electrocardiographic (ECG) screening for atrial fibrillation (AF), and selective screening based on an abnormal echocardiogram.
METHODS
Two strategies of portable ECG screening for AF were compared in the base case of a hypothetical asymptomatic 65-year-old man (CHA
RESULTS
ImagingScreen dominated AgeScreen, with a lower cost ($54 823 vs $57842) and better outcome (11.56 vs 11.52 QALY over 20 years). Monte Carlo simulation demonstrated that 61% of observations were more efficacious with ImagingScreen, with cost below willingness to pay. The main cost determinants were annual costs of stroke or heart failure and AF detection rates. ImagingScreen was more cost-effective for AF detection rates up to 14%, and more cost-effective across a range of annual stroke ($24 000-$102 000) and heart failure ($4000-$12 000) costs.
CONCLUSION
In patients with a previous echocardiogram, AF screening of those with baseline clinical and imaging risk parameters is more cost-effective than age-based screening.
Types de publication
Case Reports
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
760-772Subventions
Organisme : Siemens Healthcare Australia
Organisme : Tasmanian Community Fund
ID : 26Large00052
Organisme : Diabetes Australia
ID : Y14G-MART1
Organisme : National Health and Medical Research Council
ID : 1149692
Organisme : Heart Foundation
Informations de copyright
© 2022 Royal Australasian College of Physicians.
Références
Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B et al. 2016 ESC guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur J Cardiothorac Surg 2016; 50: e1-e88.
Svennberg E, Engdahl J, Al-Khalili F, Friberg L, Frykman V, Rosenqvist M. Mass screening for untreated atrial fibrillation: the STROKESTOP study. Circulation 2015; 131: 2176-84.
Halcox JP, Wareham K, Cardew A, Gilmore M, Barry JP, Phillips C et al. Assessment of remote heart rhythm sampling using the AliveCor heart monitor to screen for atrial fibrillation: the REHEARSE-AF study. Circulation 2017; 136: 1784-94.
Pathak RK, Middeldorp ME, Meredith M, Mehta AB, Mahajan R, Wong CX et al. Long-term effect of goal-directed weight management in an atrial fibrillation cohort: a long-term follow-up study (LEGACY). J Am Coll Cardiol 2015; 65: 2159-69.
Wilson JMG, Jungner G, World Health Organization. Principles and Practice of Screening for Disease. Geneva, Switzerland: World Health Organization; 1968.
Curry SJ, Krist AH, Owens DK, Barry MJ, Caughey AB, Davidson KW et al. Screening for atrial fibrillation with electrocardiography: US Preventive Services Task Force recommendation statement. JAMA 2018; 320: 478-84.
Proietti M, Mairesse GH, Goethals P, Scavee C, Vijgen J, Blankoff I et al. A population screening programme for atrial fibrillation: a report from the Belgian Heart Rhythm Week screening programme. Europace 2016; 18: 1779-86.
Lowres N, Neubeck L, Salkeld G, Krass I, McLachlan AJ, Redfern J et al. Feasibility and cost-effectiveness of stroke prevention through community screening for atrial fibrillation using iPhone ECG in pharmacies. Thromb Haemost 2014; 111: 1167-76.
Hammoudi N, Duprey M, Regnier P, Achkar M, Boubrit L, Preud'homme G et al. Pretest probability of a normal echocardiography: validation of a simple and practical algorithm for routine use. Arch Cardiovasc Dis 2014; 107: 105-11.
Ramkumar SO, Ochi A, Kawakami H, Yang H, Potter EL, D'Elia N et al. Echocardiographic risk assessment to guide screening for atrial fibrillation. J Am Soc Echocardiogr 2019; 32: 1259-67.
Ramkumar S, Ochi A, Yang H, Nerlekar N, D'Elia N, Potter EL et al. Association between socio-economic status and incident atrial fibrillation. Intern Med J 2019; 49: 1244-51.
Bassand J-P, Accetta G, Camm AJ, Cools F, Fitzmaurice DA, Fox KA et al. Two-year outcomes of patients with newly diagnosed atrial fibrillation: results from GARFIELD-AF. Eur Heart J 2016; 37: 2882-9.
Johnson ME, Lefèvre C, Collings S-L, Evans D, Kloss S, Ridha E et al. Early real-world evidence of persistence on oral anticoagulants for stroke prevention in non-valvular atrial fibrillation: a cohort study in UKprimary care. BMJ Open 2016; 6: e011471.
Connolly SJ, Ezekowitz MD, Yusuf S, Eikelboom J, Oldgren J, Parekh A et al. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med 2009; 361: 1139-51.
Granger CB, Alexander JH, McMurray JJ, Lopes RD, Hylek EM, Hanna M et al. Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med 2011; 365: 981-92.
Guo Y, Wang H, Zhang H, Liu T, Liang Z, Xia Y et al. Mobile photoplethysmographic technology to detect atrial fibrillation. J Am Coll Cardiol 2019; 74: 2365-75.
Thomas L, Marwick TH, Popescu BA, Donal E, Badano LP. Left atrial structure and function, and left ventricular diastolic dysfunction: JACC state-of-the-art review. J Am Coll Cardiol 2019; 73: 1961-77.
Svennberg CE, Engdahl J, Frykman-Kull V, Friberg L, Levin LA, Rosenqvist M. Mass screening for silent atrial fibrillation in high risk patients-preliminary results from the STROKESTOP trial. Eur Heart J 2013; 34: 809.
Harrington AR, Armstrong EP, Nolan PE Jr, Malone DC. Cost-effectiveness of apixaban, dabigatran, rivaroxaban, and warfarin for stroke prevention in atrial fibrillation. Stroke 2013; 44: 1676-81.
Diener H-C, Connolly SJ, Ezekowitz MD, Wallentin L, Reilly PA, Yang S et al. Dabigatran compared with warfarin in patients with atrial fibrillation and previous transient ischaemic attack or stroke: a subgroup analysis of the RE-LY trial. Lancet Neurol 2010; 9: 1157-63.
Kamel H, Johnston SC, Easton JD, Kim AS. Cost-effectiveness of dabigatran compared with warfarin for stroke prevention in patients with atrial fibrillation and prior stroke or transient ischemic attack. Stroke 2012; 43: 881-3.
Hemphill JC, Bonovich DC, Besmertis L, Manley GT, Johnston SC. The ICH score. Stroke 2001; 32: 891-7.
Patel MR, Mahaffey KW, Garg J, Pan G, Singer DE, Hacke W et al. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med 2011; 365: 883-91.
Yeh RW, Sidney S, Chandra M, Sorel M, Selby JV, Go AS. Population trends in the incidence and outcomes of acute myocardial infarction. N Engl J Med 2010; 362: 2155-65.
Goto S, Angchaisuksiri P, Bassand JP, Camm AJ, Dominguez H, Illingworth L et al. Management and 1-year outcomes of patients with newly diagnosed atrial fibrillation and chronic kidney disease: results from the prospective GARFIELD-AF registry. J Am Heart Assoc 2019; 8: e010510.
Jacobs MS, van Hulst M, Postma MJ, Kaasenbrood F, Tieleman RG. Cost-effectiveness of screening for atrial fibrillation in primary care with a handheld, single-lead electrocardiogram device in The Netherlands. Europace 2016; 20: 12-8.
Hart RG, Pearce LA, Aguilar MI. Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation. Ann Intern Med 2007; 146: 857-67.
Schleinitz MD, Weiss JP, Owens DK. Clopidogrel versus aspirin for secondary prophylaxis of vascular events: a cost-effectiveness analysis. Am J Med 2004; 116: 797-806.
Lloyd-Jones DM, Larson MG, Leip EP, Beiser A, D'Agostino RB, Kannel WB et al. Lifetime risk for developing congestive heart failure: the Framingham Heart Study. Circulation 2002; 106: 3068-72.
Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M et al. Heart disease and stroke statistics--2015 update: a report from the American Heart Association. Circulation 2015; 131: e29-322.
Nolan MT, Plana JC, Thavendiranathan P, Shaw L, Si L, Marwick TH. Cost-effectiveness of strain-targeted cardioprotection for prevention of chemotherapy-induced cardiotoxicity. Int J Cardiol 2016; 212: 336-45.
Freeman JV, Zhu RP, Owens DK, Garber AM, Hutton DW, Go AS et al. Cost-effectiveness of dabigatran compared with warfarin for stroke prevention in atrial fibrillation. Ann Intern Med 2011; 154: 1-11.
Baeten SA, van Exel NJA, Dirks M, Koopmanschap MA, Dippel DW, Niessen LW. Lifetime health effects and medical costs of integrated stroke services-a non-randomized controlled cluster-trial based life table approach. Cost Eff Resour Alloc 2010; 8: 21.
Gaziano TA, Fonarow GC, Claggett B, Chan WW, Deschaseaux-Voinet C, Turner SJ et al. Cost-effectiveness analysis of sacubitril/valsartan vs enalapril in patients with heart failure and reduced ejection fraction. JAMA Cardiol 2016; 1: 666-72.
Göhler A, Geisler BP, Manne JM, Kosiborod M, Zhang Z, Weintraub WS et al. Utility estimates for decision-analytic modeling in chronic heart failure-health states based on New York Heart Association classes and number of rehospitalizations. Value Health 2009; 12: 185-7.
Sullivan PW, Ghushchyan V. Preference-based EQ-5D index scores for chronic conditions in the United States. Med Decis Making 2006; 26: 410-20.
Heidenreich PA, Masoudi FA, Maini B, Chou TM, Foster E, Schiller NB et al. Echocardiography in patients with suspected endocarditis: a cost-effectiveness analysis. Am J Med 1999; 107: 198-208.
Holloway R, Witter JD, Lawton K, Lipscomb J, Samsa G. Inpatient costs of specific cerebrovascular events at five academic medical centers. Neurology 1996; 46: 854-60.
Reddy VY, Akehurst RL, Amorosi SL, Gavaghan MB, Hertz DS, Holmes DR Jr. Cost-effectiveness of left atrial appendage closure with the WATCHMAN device compared with warfarin or non-vitamin K antagonist oral anticoagulants for secondary prevention in nonvalvular atrial fibrillation. Stroke 2018; 49: 1464-70.
Kauf TL, Velazquez EJ, Crosslin DR, Weaver WD, Diaz R, Granger CB et al. The cost of acute myocardial infarction in the new millennium: evidence from a multinational registry. Am Heart J 2006; 151: 206-12.
Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Colvin MM et al. 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the Management of Heart Failure. A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Circulation 2017; 70: 776-803.
Aronsson M, Svennberg E, Rosenqvist M, Engdahl J, Al-Khalili F, Friberg L et al. Designing an optimal screening program for unknown atrial fibrillation: a cost-effectiveness analysis. Europace 2017; 19: 1650-6.
Ramkumar S, Nerlekar N, D'Souza D, Pol DJ, Kalman JM, Marwick TH. Atrial fibrillation detection using single lead portable electrocardiographic monitoring: a systematic review and meta-analysis. BMJ Open 2018; 8: e024178.
Perez MV, Mahaffey KW, Hedlin H, Rumsfeld JS, Garcia A, Ferris T et al. Large-scale assessment of a smartwatch to identify atrial fibrillation. N Engl J Med 2019; 381: 1909-17.