Socioeconomic and geographic differences in ablation of atrial fibrillation in Norway - a national cohort study

Background

The aim of this study was to analyse whether there are patient related or geographic differences in the use of catheter ablation among atrial fibrillation patients in Norway.

Methods

National population-based data on individual level of all Norwegians aged 25 to 75 diagnosed with atrial fibrillation from 2008 to 2017 were used to study the proportion treated with catheter ablation. Survival analysis, by Cox regression with attained age as time scale, separately by gender, was applied to examine the associations between ablation probability and educational level, income level, place of residence, and follow-up time.

Results

Substantial socioeconomic and geographic variation was documented. Atrial fibrillation patients with high level of education and high income were more frequently treated with ablation, and the education effect increased with increasing age. Patients living in the referral area of St. Olavs Hospital Trust had around three times as high ablation rates as patients living in the referral area of Finnmark Hospital Trust.

Conclusions

Differences in health literacy, patient preference and demands are probably important causes of socioeconomic variation, and studies on how socioeconomic status influences the choice of treatment are warranted. Some of the geographic variation may reflect differences in ablation capacity. However, geographic variation related to differences in clinical practice and provider preferences implies a need for clearer guidelines, both at the specialist level and at the referring level.

Supplementary Information

The online version contains supplementary material available at (10.1186/s12889-022-12628-9).

Comparison of cost-effectiveness of implantable cardioverter defibrillator therapy in patients for primary prevention in Latin America: an analysis using the Improve SCA study

OBJECTIVE

The mortality benefit of implantable cardioverter defibrillators (ICDs) for primary prevention (PP) of sudden cardiac arrest (SCA) has been well-established, but ICD therapy remains globally underutilized. The results of the Improve SCA study showed a 49% relative risk reduction in all-cause mortality among ICD patients with 1.5 primary prevention (1.5PP) characteristics (patients with one or more risk factors, p < 0.0001). We evaluated the cost-effectiveness of ICD compared to no ICD therapy among patients with 1.5PP characteristics in three Latin American countries and analyzed the factors involved in cost-effectiveness.

METHODS

We used a published Markov model that compares costs and outcomes of ICD to no ICD therapy from local payers' perspective and included country-specific and disease-specific inputs from the Improve SCA study and current literature. We used WHO-recommended willingness-to-pay (WTP) thresholds to assess cost-effectiveness and compared model outcomes between countries.

RESULTS

Incremental costs per QALY (quality-adjusted life year) saved by ICD compared to no ICD therapy are Colombian Pesos COP$46,729,026 in Colombia, Mexican Pesos MXN$246,016 in Mexico, and Uruguayan Pesos UYU$1,213,614 in Uruguay in the base case scenario; all three figures are between 1-3-times GDP per capita for each country. One-way and probabilistic sensitivity analyses confirm the base case scenario results. Non-cardiac accumulated deaths are lower in Mexico, resulting in a comparatively increased cost-effective ICD therapy.

LIMITATIONS

The Improve SCA study was not randomized, so clinical results could be biased; however, measures were taken to reduce this bias. Costs and benefits were modelled beyond the timeline of direct observation in the Improve SCA study.

CONCLUSIONS

ICD therapy is cost-effective in Mexico and Uruguay and potentially cost-effective in Colombia for a 1.5PP population. Variability in ICER estimates by country can be explained by differences in non-cardiac deaths and cost inputs.