The costs of care in atrial fibrillation and the effect of treatment modalities in Germany

Cost-utility of VISITAG SURPOINT in catheter ablation of atrial fibrillation

BACKGROUND

Clinical studies have demonstrated the safety, efficacy, and efficiency of VISITAG SURPOINT® (VS), which provides important lesion markers during catheter ablation (CA) of atrial fibrillation (AF). The present study evaluated the cost-effectiveness of CA with VS compared to CA without VS in AF from the publicly-funded German and Belgium healthcare perspectives.

METHODS

We constructed a two-stage cost utility model that included a decision tree to simulate clinical events, costs, and utilities during the first year after the index procedure and a Markov model to simulate transitions between health states throughout a patient's lifetime. Model inputs included published literature, a meta-analysis of randomized controlled trials AF outcomes, and publicly available administrative data on costs. Deterministic and probabilistic sensitivity analyses were conducted to determine the robustness of the model.

RESULTS

CA with VS was associated with lower per patient costs vs CA without VS (Germany: €3295 vs. €3936, Belgium: €3194 vs. €3814) and similar quality-adjusted life-years (QALYs) per patient (Germany: 5.35 vs. 5.34, Belgium: 5.68 vs. 5.67). CA with VS was the dominant ablation strategy (incremental cost-effectiveness ratios: Germany: €-52,455/QALY, Belgium: €-50,676/QALY). The model results were robust and not highly sensitive to variation to individual parameters with regard to QALYs or costs. Freedom from AF and procedure time had the greatest impact on model results, highlighting the importance of these outcomes in ablation.

CONCLUSIONS

CA with VS resulted in cost savings and QALY gains compared to CA without VS, supporting the increased adoption of VS in CA in Germany and Belgium.

The Association between Diagnosis-to-Ablation Time and the Recurrence of Atrial Fibrillation: A Retrospective Cohort Study

BACKGROUND

Catheter ablation (CA) for atrial fibrillation (AF) is superior to antiarrhythmic drugs in maintaining sinus rhythm. Novel evidence suggests that increasing the time between the first diagnosis of AF and ablation, or diagnosis-to-ablation time (DAT), is a predictor for AF recurrence post-ablation.

PURPOSE

Our primary objective was to investigate the relationship between DAT and AF recurrence after a first ablation.

METHODS

Patients with AF who underwent CA in our center were enrolled consecutively, and a retrospective analysis was performed. DAT was treated as a continuous variable and reported as a median for the group with recurrence and the group without recurrence. DAT was also considered as a categorical variable and patients were stratified into three categories: DAT < 1 year, DAT < 2 years, and DAT < 4 years.

RESULTS

The cohort included 107 patients, with a mean age of 54.3 ± 11.7 years. Mean DAT was significantly longer in those with AF recurrence: 4.9(3.06) years versus 3.99(3.5) (p = 0.04). The Kaplan-Meier curve revealed a higher likelihood of AF-free status over time for patients with DAT < 2 years compared to those with DAT > 2 years (p = 0.04). Cox multivariate analysis indicated that left atrial volume index (LAVI), obstructive sleep apnoea (OSA), and DAT > 2 years were independently associated with AF recurrence after a single AF ablation procedure (p = 0.007, p = 0.02, and p = 0.03, respectively).

CONCLUSION

A shorter duration between the first AF diagnosis and AF ablation is associated with an increased likelihood of procedural success after a single AF ablation procedure.

The economic impact of a local, collaborative, stepped, and personalized care management for older people with chronic diseases: results from the randomized comparative effectiveness LoChro-trial

BACKGROUND

Within the ageing population of Western societies, an increasing number of older people have multiple chronic conditions. Because multiple health problems require the involvement of several health professionals, multimorbid older people often face a fragmented health care system. To address these challenges, in a two-group parallel randomized controlled trial, a newly developed care management approach (LoChro-Care) was compared with usual care.

METHODS

LoChro-Care consists of individualized care provided by chronic care managers with 7 to 16 contacts over 12 months. Patients aged 65 + with chronic conditions were recruited from inpatient and outpatient departments. Healthcare utilization costs are calculated by using an adapted version of the generic, self-reporting FIMA©-questionnaire with the application of standardized unit costs. Questionnaires were given at 3 time points (T0 baseline, T1 after 12 months, T2 after 18 months). The primary outcome was overall 3-month costs of healthcare utilization at T1 and T2. The data were analyzed using generalized linear models with log-link and gamma distribution and adjustment for age, sex, level of care as well as the 3-month costs of care at T0.

RESULTS

Three hundred thirty patients were analyzed. The results showed no significant difference in the costs of healthcare utilization between participants who received LoChro-Care and those who received usual care, regardless of whether the costs were evaluated 12 (adjusted mean difference € 130.99, 95%CI €-1477.73 to €1739.71, p = 0.873) or 18 (adjusted mean difference €192.99, 95%CI €-1894.66 to €2280.65, p = 0.856) months after the start of the intervention.

CONCLUSION

This study revealed no differences in costs between older people receiving LoChro-Care or usual care. Before implementing the intervention, further studies with larger sample sizes are needed to provide robust evidence on the cost effects of LoChro-Care.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS): DRKS00013904, https://drks.de/search/de/trial/DRKS00013904 ; date of first registration 02/02/2018.

Estimating the cost impact of atrial fibrillation using a prospective cohort study and population-based controls

AIMS

Atrial fibrillation (AF) costs are expected to be substantial, but cost comparisons with the general population are scarce. Using data from the prospective Swiss-AF cohort study and population-based controls, we estimated the impact of AF on direct healthcare costs from the Swiss statutory health insurance perspective.

METHODS

Swiss-AF patients, enrolled from 2014 to 2017, had documented, prevalent AF. We analysed 5 years of follow-up, where clinical data, and health insurance claims in 42% of the patients were collected on a yearly basis. Controls from a health insurance claims database were matched for demographics and region. The cost impact of AF was estimated using five different methods: (1) ordinary least square regression (OLS), (2) OLS-based two-part modelling, (3) generalised linear model-based two-part modelling, (4) 1:1 nearest neighbour propensity score matching and (5) a cost adjudication algorithm using Swiss-AF data non-comparatively and considering clinical data. Cost of illness at the Swiss national level was modelled using obtained cost estimates, prevalence from the Global Burden of Disease Project, and Swiss population data.

RESULTS

The 1024 Swiss-AF patients with available claims data were compared with 16 556 controls without known AF. AF patients accrued CHF5600 (EUR5091) of AF-related direct healthcare costs per year, in addition to non-AF-related healthcare costs of CHF11100 (EUR10 091) per year accrued by AF patients and controls. All five methods yielded comparable results. AF-related costs at the national level were estimated to amount to 1% of Swiss healthcare expenditure.

CONCLUSIONS

We robustly found direct medical costs of AF patients were 50% higher than those of population-based controls. Such information on the incremental cost burden of AF may support healthcare capacity planning.

Cost-effectiveness of early rhythm control vs. usual care in atrial fibrillation care: an analysis based on data from the EAST-AFNET 4 trial

AIMS

The randomized, controlled EAST-AFNET 4 trial showed that early rhythm control (ERC) reduces the rate of a composite primary outcome (cardiovascular death, stroke, or hospitalization for worsening heart failure or acute coronary syndrome) by ∼20%. The current study examined the cost-effectiveness of ERC compared to usual care.

METHODS AND RESULTS

This within-trial cost-effectiveness analysis was based on data from the German subsample of the EAST-AFNET 4 trial (n = 1664/2789 patients). Over a 6-year time horizon and from a healthcare payer's perspective, ERC was compared to usual care regarding costs (hospitalization and medication) and effects (time to primary outcome; years survived). Incremental cost-effectiveness ratios (ICERs) were calculated. Cost-effectiveness acceptability curves were constructed to visualize uncertainty. Early rhythm control was associated with higher costs [+€1924, 95% CI (-€399, €4246)], resulting in ICERs of €10 638 per additional year without a primary outcome and €22 536 per life year gained. The probability of ERC being cost-effective compared to usual care was ≥95% or ≥80% at a willingness-to-pay value of ≥€55 000 per additional year without a primary outcome or life year gained, respectively.

CONCLUSION

From a German healthcare payer's perspective, health benefits of ERC may come at reasonable costs as indicated by the ICER point estimates. Taking statistical uncertainty into account, cost-effectiveness of ERC is highly probable at a willingness-to-pay value of ≥€55 000 per additional life year or year without a primary outcome. Future studies examining the cost-effectiveness of ERC in other countries, subgroups with higher benefit from rhythm control therapy, or cost-effectiveness of different modes of ERC are warranted.

Process optimization for atrial fibrillation ablation

AIMS

In the light of an increasing prevalence of atrial fibrillation (AF) and growing evidence for the superiority of early invasive rhythm control, the demand for ablation therapy is rising. Accordingly, ablation centres will have to maximize their capacity by either adding electrophysiology laboratory resources or optimizing process management. In order to optimize process management, we applied "Lean Six Sigma" method to a single ablation center. We compared procedural parameters, acute efficacy and safety of cryoballoon pulmonary vein isolation (cryoPVI) before and after modifications.

METHODS AND RESULTS

Patients (n = 713) undergoing cryoPVI (108 before and 605 after process optimization) were analysed. Within 3 years of process optimization, electrophysiology laboratory occupancy time (150.7 ± 44.4 vs. 94 ± 22.1 min, P < 0.001), procedure time (84.5 ± 21-47.4 ± 12 min, P < 0.001), left-atrial dwell time (53.9 ± 18.4-31.9 ± 9.9 min, P < 0.001), and fluoroscopy time (15.8 ± 5.1 vs. 6.2 ± 2.8 min, P < 0.001) decreased. Contrast dye use (116 ± 35 vs. 27 ± 15 mL, P < 0.001) and radiation dose (893 ± 1078 vs. 253 ± 249 cGy cm2, P < 0.001) were reduced by ∼77 and ∼72%, respectively. There was no difference in safety endpoint occurrence (3.7 vs. 1.5%, P = 0.11).

CONCLUSION

The process optimization of cryoPVI for AF therapy using the 'Lean Six Sigma' method significantly increases efficiency without compromising patient safety.

Keeping it Simple: Balloon Devices for Atrial Fibrillation Ablation Therapy

Atrial fibrillation is a common disease of increasing prevalence. Catheter ablation has evolved into an established therapeutic option that mainly aims to electrically isolate the pulmonary veins from atrial myocardium. The traditional method comprises point-by-point radiofrequency current ablation guided by electroanatomical mapping and has proven to be effective and safe in experienced hands. However, this approach is technically highly demanding and associated with a long learning curve, limiting its widespread utilization. To address these shortcomings, simplified ablation tools for pulmonary vein isolation are needed. In this context, balloon devices promise to ease the procedure by approaching the entire orifice of a targeted pulmonary vein in a single maneuver. This requires less catheter manipulation in the left atrium and often allows ablation of a large volume of tissue with a single application of ablative energy. Two balloon devices-one using cryoenergy, the other laser energy-have already been established in clinical routine and have demonstrated noninferiority when compared with radiofrequency ablation in large randomized trials. More balloon devices are on the verge of being introduced into clinical practice and bear the potential to expand the interventional electrophysiologist's armamentarium when treating atrial fibrillation. The authors review the use of the established balloon devices available for atrial fibrillation ablation and provide a detailed outlook on upcoming balloon technologies, including 3 different balloons utilizing radiofrequency energy as well as a novel cryoballoon.

Use of mHealth Devices to Screen for Atrial Fibrillation: Cost-Effectiveness Analysis

BACKGROUND

With an estimated prevalence of around 3% and an about 2.5-fold increased risk of stroke, atrial fibrillation (AF) is a serious threat for patients and a high economic burden for health care systems all over the world. Patients with AF could benefit from screening through mobile health (mHealth) devices. Thus, an early diagnosis is possible with mHealth devices, and the risk for stroke can be markedly reduced by using anticoagulation therapy.

OBJECTIVE

The aim of this work was to assess the cost-effectiveness of algorithm-based screening for AF with the aid of photoplethysmography wrist-worn mHealth devices. Even if prevented strokes and prevented deaths from stroke are the most relevant patient outcomes, direct costs were defined as the primary outcome.

METHODS

A Monte Carlo simulation was conducted based on a developed state-transition model; 30,000 patients for each CHA₂DS₂-VASc (Congestive heart failure, Hypertension, Age≥75 years, Diabetes mellitus, Stroke, Vascular disease, Age 65-74 years, Sex category [female]) score from 1 to 9 were simulated. The first simulation served to estimate the economic burden of AF without the use of mHealth devices. The second simulation served to simulate the economic burden of AF with the use of mHealth devices. Afterwards, the groups were compared in terms of costs, prevented strokes, and deaths from strokes.

RESULTS

The CHA₂DS₂-VASc score as well as the electrocardiography (ECG) confirmation rate had the biggest impact on costs as well as number of strokes. The higher the risk score, the lower were the costs per prevented stroke. Higher ECG confirmation rates intensified this effect. The effect was not seen in groups with lower risk scores. Over 10 years, the use of mHealth (assuming a 75% ECG confirmation rate) resulted in additional costs (€1=US $1.12) of €441, €567, €536, €520, €606, €625, €623, €692, and €847 per patient for a CHA₂DS₂-VASc score of 1 to 9, respectively. The number of prevented strokes tended to be higher in groups with high risk for stroke. Higher ECG confirmation rates led to higher numbers of prevented strokes. The use of mHealth (assuming a 75% ECG confirmation rate) resulted in 25 (7), -68 (-54), 98 (-5), 266 (182), 346 (271), 642 (440), 722 (599), 1111 (815), and 1116 (928) prevented strokes (fatal) for CHA₂DS₂-VASc score of 1 to 9, respectively. Higher device accuracy in terms of sensitivity led to even more prevented fatal strokes.

CONCLUSIONS

The use of mHealth devices to screen for AF leads to increased costs but also a reduction in the incidence of stroke. In particular, in patients with high CHA₂DS₂-VASc scores, the risk for stroke and death from stroke can be markedly reduced.

Diagnostic accuracy of smart gadgets/wearable devices in detecting atrial fibrillation: A systematic review and meta-analysis

BACKGROUND

Recently, smart devices have been used for medical purposes, particularly to screen for atrial fibrillation. However, current data on the diagnostic performance of these devices are scarce.

AIMS

We performed a systemic review and meta-analysis to assess the accuracy of atrial fibrillation diagnosis by smart gadgets/wearable devices.

METHODS

We comprehensively searched the MEDLINE, EMBASE and Cochrane databases for all works since the inception of each database until January 2020. Included in this review were published observational studies of the diagnostic accuracy of smartphones or smartwatches in detecting atrial fibrillation. We calculated the area under the summary receiver operating characteristic curves and pooled sensitivities and specificities.

RESULTS

Participants in our study were from the general population or were patients with underlying atrial fibrillation. In the overall analyses, the areas under the summary receiver operating characteristic curves were 0.96 and 0.94 for smartphones and smartwatches, respectively. Smartphones had a sensitivity of 94% and a specificity of 96%, and smartwatches showed similar diagnostic accuracy, with a specificity of 94% and a sensitivity of 93%. In subgroup analyses, we found no difference in diagnostic accuracy between photoplethysmography and single-lead electrocardiography.

CONCLUSIONS

This study suggests that smart devices have similar diagnostic accuracies. Regarding atrial fibrillation detection methods, there was also no difference between photoplethysmography and single-lead electrocardiography. However, further studies are warranted to determine their clinical implications in atrial fibrillation management.

Cost-Effectiveness of Obstructive Sleep Apnea Screening and Treatment Before Catheter Ablation for Symptomatic Atrial Fibrillation

Background: Although management of obstructive sleep apnea (OSA) has been recommended to improve outcomes of catheter ablation (CA) in patients with symptomatic atrial fibrillation (AF), the most cost-effective way of preprocedural OSA screening is undetermined. This study assessed the cost-effectiveness of OSA management before CA for symptomatic AF.

Methods and Results: A Markov model was developed to assess the cost-effectiveness of 3 OSA detection strategies before CA: no screening; Type 3 portable monitor (PM)-guided screening; and polysomnography (PSG)-guided screening. The target population consisted of a hypothetical cohort of patients aged 65 years with symptomatic AF, with 50% prevalence of OSA. We used a 5-year horizon, with sensitivity analyses for significant variables and scenario analyses for lower and higher OSA prevalence (30% and 70%, respectively). In the base-case, both types of OSA screening were dominant (less costly and more effective) relative to no screening. Although PSG-guided management was more effective than PM-guided management, it was more costly and therefore did not show clear benefit. These findings were replicated in cohorts with lower and higher OSA risks.

Conclusions: OSA screening before CA is cost-effective in patients with symptomatic AF, with PM screening being the most cost-effective. Physicians should consider OSA management using this simple tool in the decision making for treatment of symptomatic AF.

A novel integrated care concept (NICC) versus standard care in the treatment of chronic cardiovascular diseases: protocol for the randomized controlled trial CardioCare MV

Background

Cardiovascular diseases are the major cause of death globally and represent a major economic burden on health care systems. Positive effects of disease management programs have been shown for patients with heart failure (HF). Remote monitoring and telemonitoring with active intervention are beneficial in atrial fibrillation (AF) and therapy-resistant hypertension (TRH), respectively. For these patients, we have developed a novel integrated care concept (NICC) which combines telemedicine with intensive support by a care center, including a call center, an integrated care network including inpatient and outpatient care providers and guideline therapy for patients.

Methods

The aim of the study is to demonstrate the superiority of NICC over guideline therapy alone. The trial is designed as open-label, bi-center, parallel-group design with two groups and a blinded observer. Patients will be included if they are either inpatients or if they are referred to the outpatient clinic of the hospitals by their treating physician. Randomization will be done individually with stratification by cardiovascular disease (AF, HF, TRH), center and admission type. Primary endpoints are based on the 1-year observation period after randomization. The first primary endpoint is the composite endpoint consisting of mortality, stroke and myocardial infarction. The number of hospitalizations form the second primary endpoint. The third primary endpoint is identical to the first primary endpoint plus cardiac decompensation. Adjustments for multiple testing are done using a fall-back strategy. Secondary endpoints include patient adherence, health care costs, quality of life, and safety. A sample size of 2930 gives 80% power at the two-sided 2.5% test level for the first primary endpoint. The power for the second primary endpoint is 99.8% at this sample size, and it is 80% with 1086 patients.

Discussion

This study will inform care providers whether quality of care can be improved by an integrated care concept providing telemedicine through a round-the-clock call center approach. We expect that cost of the NICC will be lower than standard care because of reduced hospitalizations. If the study has a positive result, NICC is planned to be immediately rolled out in the federal state of Mecklenburg-West Pomerania and other federal states in Germany. The trial will also guide additional research to disentangle the effects of this complex intervention.

Trial registration

DRKS, ID: DRKS00013124. Registered on 5 October 2017;

ClinicalTrials.gov, ID: NCT03317951. Registered on 17 October 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2502-1) contains supplementary material, which is available to authorized users.

The Impact of Cryoballoon Versus Radiofrequency Ablation for Paroxysmal Atrial Fibrillation on Healthcare Utilization and Costs: An Economic Analysis From the FIRE AND ICE Trial

BACKGROUND

This study sought to assess payer costs following cryoballoon or radiofrequency current (RFC) catheter ablation of paroxysmal atrial fibrillation in the randomized FIRE AND ICE trial.

METHODS AND RESULTS

A trial period analysis of healthcare costs evaluated the impact of ablation modality (cryoballoon versus RFC) on differences in resource use and associated payer costs. Analyses were based on repeat interventions, rehospitalizations, and cardioversions during the trial, with unit costs based on 3 national healthcare systems (Germany [€], the United Kingdom [£], and the United States [$]). Total payer costs were calculated by applying standard unit costs to hospital stays, using International Classification of Diseases, 10th Revision diagnoses and procedure codes that were mapped to country-specific diagnosis-related groups. Patients (N=750) randomized 1:1 to cryoballoon (n=374) or RFC (n=376) ablation were followed for a mean of 1.5 years. Resource use was lower in the cryoballoon than the RFC group (205 hospitalizations and/or interventions in 122 patients versus 268 events in 154 patients). The cost differences per patient in mean total payer costs during follow-up were €640, £364, and $925 in favor of cryoballoon ablation (P=0.012, 0.013, and 0.016, respectively). This resulted in trial period total cost savings of €245 000, £140 000, and $355 000.

CONCLUSIONS

When compared with RFC ablation, cryoballoon ablation was associated with a reduction in resource use and payer costs. In all 3 national healthcare systems analyzed, this reduction resulted in substantial trial period cost savings, primarily attributable to fewer repeat ablations and a reduction in cardiovascular rehospitalizations with cryoballoon ablation.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Identifier: NCT01490814.

Costs of major intracranial, gastrointestinal and other bleeding events in patients with atrial fibrillation - a nationwide cohort study

Background

Use of oral anticoagulation therapy in patients with atrial fibrillation (AF) involves a trade-off between a reduced risk of ischemic stroke and an increased risk of bleeding events. Different anticoagulation therapies have different safety profiles and data on the societal costs of both ischemic stroke and bleeding events are necessary for assessing the cost-effectiveness and budgetary impact of different treatment options. To our knowledge, no previous studies have estimated the societal costs of bleeding events in patients with AF.

The objective of this study was to estimate the 3-years societal costs of first-incident intracranial, gastrointestinal and other major bleeding events in Danish patients with AF.

Methods

The study was an incidence-based cost-of-illness study carried out from a societal perspective and based on data from national Danish registries covering the period 2002-2012. Costs were estimated using a propensity score matching and multivariable regression analysis (first difference OLS) in a cohort design.

Results

Average 3-years societal costs attributable to intracranial, gastrointestinal and other major bleeding events were 27,627, 17,868, and 12,384 EUR per patient, respectively (2015 prices). Existing evidence shows that the corresponding costs of ischemic stroke were 24,084 EUR per patient (2012 prices). The average costs of bleeding events did not differ between patients with AF who were on oral anticoagulation therapy prior to the event and patients who were not.

Conclusions

The societal costs attributable to major bleeding events in patients with AF are significant. Intracranial haemorrhages are most costly to society with average costs of similar magnitude as the costs of ischemic stroke. The average costs of gastrointestinal and other major bleeding events are lower than the costs of intracranial haemorrhages, but still substantial. Knowledge about the relative size of the costs of bleeding events compared to ischemic stroke in patients with AF constitutes valuable evidence for decisions-makers in Denmark as well as in other countries.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2331-z) contains supplementary material, which is available to authorized users.

Cost effectiveness of left atrial appendage closure with the Watchman device for atrial fibrillation patients with absolute contraindications to warfarin

Aims

Atrial fibrillation (AF) patients with contraindications to oral anticoagulation have had few options for stroke prevention. Recently, a novel oral anticoagulant, apixaban, and percutaneous left atrial appendage closure (LAAC) have emerged as safe and effective therapies for stroke risk reduction in these patients. This analysis assessed the cost effectiveness of LAAC with the Watchman device relative to apixaban and aspirin therapy in patients with non-valvular AF and contraindications to warfarin therapy.

Methods and results

A cost-effectiveness model was constructed using data from three studies on stroke prevention in patients with contraindications: the ASAP study evaluating the Watchman device, the ACTIVE A trial of aspirin and clopidogrel, and the AVERROES trial evaluating apixaban. The cost-effectiveness analysis was conducted from a German healthcare payer perspective over a 20-year time horizon. Left atrial appendage closure yielded more quality-adjusted life years (QALYs) than aspirin and apixaban by 2 and 4 years, respectively. At 5 years, LAAC was cost effective compared with aspirin with an incremental cost-effectiveness ratio (ICER) of €16 971. Left atrial appendage closure was cost effective compared with apixaban at 7 years with an ICER of €9040. Left atrial appendage closure was cost saving and more effective than aspirin and apixaban at 8 years and remained so throughout the 20-year time horizon.

Conclusions

This analysis demonstrates that LAAC with the Watchman device is a cost-effective and cost-saving solution for stroke risk reduction in patients with non-valvular AF who are at risk for stroke but have contraindications to warfarin.

Economic evaluation of pharmacogenomic-guided warfarin treatment for elderly Croatian atrial fibrillation patients with ischemic stroke

BACKGROUND & METHODS

Economic evaluation in genomic medicine is an emerging discipline to assess the cost-effectiveness of genome-guided treatment. Here, we developed a pharmaco-economic model to assess whether pharmacogenomic (PGx)-guided warfarin treatment of elderly ischemic stroke patients with atrial fibrillation in Croatia is cost effective compared with non-PGx therapy. The time horizon of the model was set at 1 year.

RESULTS

Our primary analysis indicates that 97.07% (95% CI: 94.08-99.34%) of patients belonging to the PGx-guided group have not had any major complications, compared with the control group (89.12%; 95% CI: 84.00-93.87%, p < 0.05). The total cost per patient was estimated at €538.7 (95% CI: €526.3-551.2) for the PGx-guided group versus €219.7 (95% CI: €137.9-304.2) for the control group. In terms of quality-adjusted life-years (QALYs) gained, total QALYs was estimated at 0.954 (95% CI: 0.943-0.964) and 0.944 (95% CI: 0.931-0.956) for the PGx-guided and the control groups, respectively. The true difference in QALYs was estimated at 0.01 (95% CI: 0.005-0.015) in favor of the PGx-guided group. The incremental cost-effectiveness ratio of the PGx-guided versus the control groups was estimated at €31,225/QALY.

CONCLUSION

Overall, our data indicate that PGx-guided warfarin treatment may represent a cost-effective therapy option for the management of elderly patients with atrial fibrillation who developed ischemic stroke in Croatia.

Clinical utility of dabigatran in United Arab Emirates. A pharmacovigilance study

Objectives:

To provide early data regarding clinical utility of dabigatran in Al-Ain, United Arab Emirates (UAE).

Methods:

This was an ethics approved retrospective cross sectional study. We retrieved a total of 76 patients who were using dabigatran from September to December 2014 in the Cardiology Clinic at Al-Ain Hospital, Al-Ain, UAE. The primary analysis was designed to test the frequency of bleeding events (rate) with dabigatran 75, 110, and 150 mg.

Results:

The mean age ± standard deviation of cohort was 67.9 ± 1.5 years (range; 29-98 years), composed of males (52.6%) with mean age of 66.3 ± 1.7 years, and females (47.4%) with mean age of 69.6 ± 1.1 years. The highest age group was those between 61-80 years (60.5%). Most comprised the age strata of ≤75 years (73.7%). The main indication for dabigatran use was atrial fibrillation. The rate of bleeding with dabigatran was 18/76 (23.7%), and melena was the leading cause of bleeding 8/76 (10.7%). The hospitalization rate was 67.1%, dabigatran withdrawal rate was 0.01%, and mortality rate was 6.5%. The cohort had exhibited incidences of minor bleeding with one fatal major bleeding, high co-morbidities, admission, and readmission, which was not directly linked to dabigatran. We did not identify any relation of death due to dabigatran.

Conclusion:

Dabigatran is a suitable alternative to warfarin obviating the need for repetitive international normalized ratio monitoring, however, it may need plasma drug monitoring.

Short-term ECG recordings for heart rate assessment in patients with chronic atrial fibrillation

INTRODUCTION

There is no consensus on the length of ECG tracing that should be recorded to represent adequate rate control in patients with atrial fibrillation (AFib). The purpose of the study was to examine whether heart rate measurements based on short-term ECGs recorded at different periods of the day may correspond to the mean heart rate and rate irregularity analyzed from standard 24-hour Holter monitoring.

MATERIAL AND METHODS

The study enrolled 50 consecutive patients with chronic AFib who underwent 24-hour Holter monitoring. Mean heart rate (mHR) and the coefficient of irregularity (CI) were assessed from 5- and 60-minute intervals of Holter recordings in different periods of the day.

RESULTS

The highest correlation in mean heart rate interval within 24 h was found during a 6-hour sample and in the periods 11.00 AM-12.00 PM, 12 PM-1.00 PM, and 1.00 PM-2.00 PM. With respect to irregularity, only the CI measurements based on a 6-hour interval (7.00 AM-1.00 AM) show a correlation > 0.08 compared to data from the 24-hour recording.

CONCLUSIONS

Only long-term (6-hour) recordings provide a high correlation within 24 h in mean heart rate interval and coefficient of irregularity. It seems that the mean heart rate interval in 1-hour periods between 11 AM and 2 PM might be predictive for 24-hour data. Short time recordings of the coefficient of irregularity of heart rate in AFib patients at this moment are not useful in clinical practice for long-term prognosis of ventricular irregularity.

The non-anticoagulation costs of atrial fibrillation management: findings from an observational study in NHS Primary Care

Background:

Atrial fibrillation (AF) management represents a significant burden on the UK NHS. Understanding this burden will be important in informing future health care planning and policy development.

Aim:

To describe the non-anticoagulation costs associated with AF management in routine UK clinical practice.

Materials, patients and methods:

A retrospective observational study of 825 patients with AF undertaken in eight UK primary care practices. Data collected from routine clinical and prescribing records of all eligible, consenting patients, for a period of up to 3 years. The first 12 weeks following diagnosis was defined as the ‘initiation phase’; the period after week 12 was defined as the ‘maintenance phase’.

Results:

Mean (SD) total cost of AF management was £941 (£1094) per patient in the initiation phase and £426 (£597) per patient-year in the maintenance phase. AF-related inpatient admissions contributed most to total costs; the mean (SD) total cost per patient in the initiation phase was £2285 (£900) for admitted and £278 (£252) for non-admitted patients. Mean maintenance phase costs per year were £1323 (£755) and £168 (£234), respectively, for admitted and non-admitted patients. Significant patient variables contributing to high cost in the initiation phase were hypertension and younger patient age, although only accounting for 6% of cost variability. Significant variables in the maintenance phase (18% of cost variability) were the presence of congestive heart failure, structural heart disease or diabetes and the frequency of day case admissions, ECGs and hospitalisations in the initiation phase.

Conclusions:

Inpatient admissions contributed most to total AF management costs. Given the burden of hospital care, future work should focus on evaluating the appropriateness and reasons for hospitalisation in patients with AF and the factors affecting length of stay, with the aim of identifying opportunities to safely reduce inpatient costs.

A number of significant patient characteristics and initiation phase variables were identified, which accounted for 18% of the variability in total maintenance phase costs. However, none of these could adequately predict high maintenance phase costs.

The burden of atrial fibrillation in the Netherlands

BACKGROUND

Atrial fibrillation (AF) is the most common sustained atrial arrhythmia and it is independently associated with an increased morbidity and mortality. As a result of the high prevalence of AF, the economic and clinical impact of the disease is substantial. This study describes the economic and clinical impact of AF in the Netherlands.

METHODS

Epidemiological data on AF in the Netherlands were projected on population estimates of the Netherlands in 2009 and combined with data on the cost of AF and its interventions.

RESULTS

Overall prevalence of AF in the Netherlands is 5.5% in the population over 55 years, corresponding to about 250,000 AF patients. The prevalence increases with age, and the mean age of AF patients is 69.3 years. Incidence of AF in the Netherlands varies with age, from 1188 new cases in the age group of 55 to 59 up to 7074 new cases in the age group 75 to 79. Total new cases amounts to 45,085 patients per year in the Netherlands. Total costs of AF in the Netherlands are <euro> 583 million, of which the majority (70%) were accounted for by hospitalisations and in-hospital procedures. Pharmacotherapeutic management of AF totalled <euro> 17 million in the Netherlands in 2009.

DISCUSSION

AF is a serious disease with a high clinical and economic burden, especially due to hospitalisations as a result of cardiovascular events. The number of patients with AF in the Netherlands is considerable and will increase with the ageing population in the future.

Cost-Effectiveness of Atrial Fibrillation Ablation

Atrial fibrillation (AF) is a frequently encountered rhythm disorder, characterized by high recurrence rate, frequent hospitalizations, reduced quality-of-life and increased the risk of mortality, heart failure and stroke. Along with these clinical complications this type of arrhythmia is the major driver of health-related expenditures. Radiofrequency catheter ablation (RFA) of atrial fibrillation has been shown to improve freedom from arrhythmia survival, reduce re-hospitalization rate and provide better quality-of-life as compared with rate control and rhythm control with antiarrhythmic therapy. Efficacy of AF ablation in terms of outcomes and costs has an evolving importance. In this review, we aimed to highlight current knowledge on AF ablation clinical outcomes based on results of randomized clinical trials and community-based studies, and overview how this improvement in clinical end-points affects costs for arrhythmia care and cost-effectiveness of AF ablation.

Cost-effectiveness of pharmacogenetics in anticoagulation: international differences in healthcare systems and costs

Genotyping patients for CYP2C9 and VKORC1 polymorphisms can improve the accuracy of dosing during the initiation of anticoagulation with vitamin K antagonists (coumarin derivatives). The anticipated degree of improvement in the safety of anticoagulation with coumarins through genotyping may vary depending on the quality of patient care, which varies both with and among countries. The management and the cost of anticoagulant care can therefore influence the cost-effectiveness of genotyping within any given country. In this article, we provide an overview of the cost-effectiveness of pharmacogenetics-guided dosing of coumarin derivatives. We describe the organization of anticoagulant care in the UK, Sweden, The Netherlands, Greece, Germany and Austria, where a genotype-guided dosing algorithm is currently being investigated as part of the EU-PACT trial. We also explore the costs of anticoagulant care for the treatment of atrial fibrillation in these countries.

Cost effectiveness of antiarrhythmic medications in patients suffering from atrial fibrillation

Atrial fibrillation (AF), a supraventricular tachycardia disorder, is the most common sustained cardiac arrhythmia affecting 1-2 % of the general population. Prevalence is highly related to age, with every fourth individual older than 40 years old developing AF during his lifetime. Due to an aging population, the prevalence of AF is estimated to at least double within the next 50 years. This article presents AF-related cost-of-illness studies and reviews 19 cost-effectiveness studies and six cost studies published roughly over the past decade, which have compared different antiarrhythmic medications for AF. A systematic literature search for studies published between June 2000 and December 2011 was conducted in PubMed using the combination of keywords ((atrial fibrillation OR atrial flutter) AND cost). Current cost-effectiveness analyses of dronedarone and the pill-in-the-pocket strategy are subject to substantial uncertainties with regard to clinical benefit. Comparing rate control with rhythm control, a cost-effectiveness advantage for rate control was shown in several but not all studies. Within antiarrhythmic drug treatments, magnesium added onto ibutilide was shown to be more cost effective than ibutilide alone. Comparing chemical and electrical cardioversion, the latter was recommended as more cost effective from the healthcare system perspective in all reviewed studies but one. Catheter ablation appeared more cost effective than antiarrhythmic drugs in the medium to long run after 3.2-63.9 years. Admissions to hospital, inpatient care and interventional procedures as well as mortality benefit are key drivers for the cost effectiveness of AF medications. No clear cost-effectiveness advantage emerged for one specific antiarrhythmic drug from the studies that compared antiarrhythmic agents. Rate control as well as catheter ablation appear more cost effective than rhythm control in the treatment of AF. Rate control treatment also seems more cost effective than electrical cardioversion in AF patients.

Atrial fibrillation: profile and burden of an evolving epidemic in the 21st century

BACKGROUND

Atrial fibrillation (AF) represents an increasing public health challenge with profound social and economic implications.

METHODS

A comprehensive synthesis and review of the AF literature was performed. Overall, key findings from 182 studies were used to describe the indicative scope and impact of AF from an individual to population perspective.

RESULTS

There are many pathways to AF including advancing age, cardiovascular disease and increased levels of obesity/metabolic disorders. The reported population prevalence of AF ranges from 2.3%-3.4% and historical trends reflect increased AF incidence. Estimated life-time risk of AF is around 1 in 4. Primary care contacts reflect whole population trends: AF-related case-presentations increase from less than 0.5% in those aged 40 years or less to 6-12% for those aged 85 years or more. Globally, AF-related hospitalisations (primary or secondary diagnosis) showed an upward trend (from ~35 to over 100 admissions/10,000 persons) during 1996 to 2006. The estimated cost of AF is greater than 1% of health care expenditure and rising with hospitalisations the largest contributor. For affected individuals, quality of life indices are poor and AF confers an independent 1.5 to 2.0-fold probability of death in the longer-term. AF is also closely linked to ischaemic stroke (3- to 5-fold risk), chronic heart failure (up to 50% develop AF) and acute coronary syndromes (up to 25% develop AF) with consistently worse outcomes reported with concurrent AF. Future projections predict at least a doubling of AF cases by 2050.

SUMMARY

AF represents an evolving, global epidemic providing considerable challenges to minimise its impact from an individual to whole society perspective.

Cardiovascular and non-cardiovascular hospital admissions associated with atrial fibrillation: a Danish nationwide, retrospective cohort study

OBJECTIVE

To examine the excess risk of hospitalisation in patients with incident atrial fibrillation (AF).

DESIGN

A nationwide, retrospective cohort study.

SETTING

Denmark.

PARTICIPANTS

Data on all admissions in Denmark from 1997 to 2009 were collected from nationwide registries. After exclusion of subjects previously admitted for AF, data on 4 602 264 subjects and 10 779 945 hospital admissions contributed to the study.

PRIMARY AND SECONDARY OUTCOME MEASURES

Age-stratified and sex-stratified admission rates were calculated for cardiovascular and non-cardiovascular admissions. Temporal patterns of readmission, relative risk and duration of frequent types of admission were calculated.

RESULTS

Of 10 779 945 hospital admissions, 729 088(6.8%) were associated with AF. Admissions for cardiovascular reasons after 1, 3 and 6 months occurred for 6.0, 14.3 and 28.4% of AF patients versus 0.2, 0.6 and 1.8 of non-AF patients. Admissions for non-cardiovascular reasons after 1, 3 and 6 months comprised 6.8, 16.1 and 33.3% of AF patients and 1.2, 3.2 and 9.7% of non-AF patients. When stratified for age, AF was associated with similar cardiovascular admission rates across all age groups, while non-cardiovascular admission rates were higher in older patients. Within each age group and for both cardiovascular and non-cardiovascular admissions, AF was associated with higher rates of admission. When adjusted for age, sex and time period, patients with AF had a relative risk of 8.6 (95% CI 8.5 to 8.6) for admissions for cardiovascular reasons and 4.0 (95% CI 4.0 to 4.0) for admission for non-cardiovascular reasons.

CONCLUSIONS

This study confirms that the burden of AF is considerable and driven by both cardiovascular and non-cardiovascular admissions. These findings underscore the importance of using clinical and pharmacological means to reduce the hospital burden of AF in Western healthcare systems.

[Patients suffering from atrial fibrillation in Germany. Characteristics, resource consumption and costs]

INTRODUCTION

Atrial fibrillation (Afib) is considered to be the most frequent form of cardiac dysrhythmia and is well known as a key risk factor for arterial thromboembolism. The incidence of Afib will increase in the future due to demographic changes as well as improved treatment options for acute and chronic heart diseases.

OBJECTIVE

The primary objectives of this analysis were to describe patient characteristics, to assess the resource consumption associated with Afib and to measure costs of direct treatment as well as consequential costs. A secondary objective was to identify factors that influence the costs or the type of Afib.

METHODS

The analysis is based on the representative ATRIUM register (Ambulantes Register zur Morbidität des Vorhofflimmerns, Ambulatory register on morbidity of atrial fibrillation), a prospective, multicenter cohort study in which general practitioners and family doctors documented the characteristics and resource utilization of consecutively enrolled patients. The documented resource consumption use was subsequently valued with unit costs. The presented results are focused on the baseline documentation and refer to the period 12 months before enrollment.

RESULTS

A total of 3,667 patients (mean age 72.1±9.2 years, 58% men) fulfilled all inclusion criteria and were included by a total of 730 doctors. The patients had an average of 2.4±1.0 risk factors and the most common was hypertension (84% of patients). The most commonly observed comorbidities were heart failure (43%) and coronary heart disease (CHD, 35%). Medicines for oral anticoagulation (86%) and beta blockers (75%) were the most frequently prescribed drugs. A total of 1/3 of all patients received a specific kind of Afib therapy (e. g. drug conversion, cardioversion) during the past 12 months. The disease-specific mean costs of the patients were 3,274±5,134 Euro, while the acute (inpatient) treatment represented the largest proportion of these total costs (1,639±3,623 Euro). Patients with high treatment costs were significantly younger and suffered from more concomitant diseases.

CONCLUSION

Atrial fibrillation is associated with significant patient-related attributable costs that are caused particularly by expenditures of inpatient stay. New, innovative treatment strategies seem to offer particular potential savings if they are able to reduce the number of hospitalizations due to Afib itself or subsequent cardiac events.

A dedicated cardioversion unit for the treatment of atrial fibrillation. Reducing costs by optimizing processes

BACKGROUND

Atrial fibrillation (AF) is the most frequent arrhythmia seen in man. Many patients are admitted to the hospital to undergo transesophageal echocardiography (TEE) for thrombus exclusion and subsequent electrical cardioversion (ECV) under deep sedation to restore sinus rhythm. The present study investigated prospectively how workflow optimization can contribute to reducing time and costs in AF patients scheduled for ECV in an outpatient setting.

METHODS

A cardioversion unit (CU) was established and equipped to perform all ECV-associated procedures. Between November 2007 and January 2009, ECV was performed in 115 patients in an outpatient setting. Three different settings were tested for ECV: (1) usual care (n = 19): preparation/follow-up in the outpatient clinic, blood testing in the central hospital laboratory (CHL), TEE in the echocardiography laboratory, and ECV in the intensive care unit; (2) optimized process 1 (n = 41): preparation/follow-up, TEE + ECV during one sedation in the CU, blood testing in the CHL; (3) optimized process 2 (n = 55): preparation/follow-up, TEE + ECV and point of care (POC) blood testing in the CU. All procedure-related costs were listed and classified according to material, human resources, and infrastructure.

RESULTS

From setting 1 to 3, there was a significant decrease in procedural time from 480 ± 105 min to 205 ± 85 min (p < 0.001). Likewise, ECV-associated costs could be reduced from 683 ± 104 <euro> to 299 ± 63 <euro> (p < 0.001).

CONCLUSION

Establishing a CU for AF enables a more than 50% reduction in procedural time and costs. A combination of TEE and ECV in one sedation and POC testing in the CU were the major contributors to this time and cost reduction.

Atrial fibrillation: the cost of illness in Sweden

AIM

To provide an estimate of the annual cost of atrial fibrillation (AF) in Sweden.

METHODS

Prevalence-based cost analysis of AF in Sweden for 2007. Direct medical (hospitalizations, hospital outpatient care, primary health care, non-pharmacological interventions, pharmaceuticals, and anticoagulation monitoring) and non-medical (transportation associated with health care visits) costs of AF, direct costs of AF complications (stroke and heart failure), and indirect costs (production loss), were included. Data were based on Swedish registries, reports and databases, published literature, and an expert panel.

RESULTS

There were 100,557 individuals with AF as primary or secondary diagnosis that were either hospitalized or treated in hospital outpatient care in 2007. The total cost of AF was estimated at <euro>708 million. The major cost driver was the direct cost of complications (54%), followed by hospitalization due to AF including AF as secondary diagnosis (18%), and production loss (12%).

CONCLUSION

This is a comprehensive, nation-based cost analysis of AF where relevant data were derived from national registries covering the entire Swedish population. The results showed that the annual cost of AF was high in comparison with other diseases, but likely to be underestimated as a conservative approach was applied in the analysis.

What are the costs of atrial fibrillation?

The costs of atrial fibrillation (AF) are linked to the general cost of managing AF patients in different health-care systems, as well as the cost of managing AF-related complications (e.g. hospitalizations and long-term complications, such as stroke). In addition, indirect medical costs, such as care for patients who do not recuperate fully from a vascular event, and non-medical costs such as loss of work force add to the costs of AF. All estimations for cost of AF and cost of AF therapy are based on assumptions and markedly influenced by these cost determinants. This urges for extreme caution not to take cost estimates at their absolute values. In fact, even relative comparisons between interventions may have different consequences in terms of direct and indirect costs in different health-care settings. While newer therapeutic options appear to increase the cost of AF management, newer antithrombotic substances and adequate rhythm control therapy also carry the promise of preventing the two major drivers of AF-related cost, hospitalizations and AF-related complications. Formal assessment of the cost of AF requires adjustment to local practice, and more data are clearly needed especially from primary care to better estimate the 'real' cost impact of AF.

Characterization of the proportion of untreated and antiplatelet therapy treated patients with atrial fibrillation

Despite the efficacy of oral anticoagulants for stroke prevention in atrial fibrillation (AF), evidence suggests that many patients with AF who should be treated with vitamin K antagonists (VKAs) are treated with antiplatelet therapy or remain untreated. The aims of this study were to determine the proportion of patients with AF in each treatment category in clinical practice and to ascertain whether treatment is appropriate for stroke risk. An extensive search of the biomedical research published since 1994 was performed. Studies delineating the treatment of patients with AF were captured. Seventy-eight studies pertaining to the treatment of patients with AF were identified; 56 studies, containing data from 1980 to 2007, met the inclusion criteria. Over time, the use of VKA therapy for stroke prevention increased, while the proportion of untreated patients decreased; antiplatelet use remained static. Looking at the more recent data, (collected from 2000 onward), the proportion of patients receiving no therapy ranged from 4% to 48% (median 18%), antiplatelet therapy from 10% to 56% (median 30%), and VKA therapy from 9% to 86% (median 52%). Although most studies showed a decrease in the proportion of antiplatelet-treated and untreated patients with increasing stroke risk (12 of 14 studies), many patients at moderate or high risk for stroke were not treated according to guidelines. In conclusion, this review shows that up to 56% of patients with AF are treated with antiplatelet therapy, and up to 48% receive no therapy regardless of stroke risk level. This may reflect the inconvenience associated with VKA use, inadequate assessment of stroke risk, or poor adherence to treatment guidelines.

[Atrial fibrillation in 2010: an increasing morbidity and mortality burden]

AF, a frequent and banal arrhythmia, is a debilitating and costly disease. The majority of patients with AF are aged 60 to 80 years, but the prevalence is as high as 10% after 80 years and the incidence increases in recent years in an "epidemic" way. AF is responsible for an excess of mortality with an relative risk between 2 and 4 depending of age and sex, especially as cardiovascular risk factors are associated. The morbidity is also important, with cerebral systemic embolism (2-3% per year), heart failure (1 patient for 3), and a total risk of hospitalization from 20 to 30% per year for AF patients with high cardiovascular risks. Whatever be the reasons for hospitalization, cardiovascular or not, in connection with AF or not, these reasons must be well analyzed, so that the risk of occurrence of hospitalization should reflect the efficacy of anti-arrhythmic drugs, or of their complications, or of the comorbidities associated with AF, so common in these older subjects. This morbidity-mortality composite endpoint should now be used in AF randomized trials, as occurring more frequently than mortality (4% per year) or embolic or hemorrhagic usual endpoints. Medico-economic consequences are significant and AF cost is almost 1% of total health spending, with 20% to 30% of the cost for anti-arrhythmic or anti-thrombotic drugs, and 50 to 60% for hospitalizations. Prevention of hospitalizations related to atrial fibrillation may represent a therapeutic target priority on the medico-economic ground.

A systems biology strategy on differential gene expression data discloses some biological features of atrial fibrillation

Atrial fibrillation (AF), the most common cardiac arrhythmia, is associated with extensive structural, contractile, and electrophysiological remodeling. In this manuscript we re-analyzed gene expression data from a microarray experiment on AF patients and control tissues, using a new paradigm based on a posteriori unsupervised strategy in which the discrimination of patients comes out from purely syntactical premises. This paradigm, more adherent to biological reality where genes work in highly connected networks, allowed us to get both a very precise patients/control discrimination and the discovery of cell adhesion/tissue modeling and inflammation processes as the main dimensions of AF.

Cost of atrial fibrillation in United States managed care organizations

INTRODUCTION

Atrial fibrillation (AF) has been shown to be associated with high healthcare costs; however, limited data are available from large-scale studies quantifying the overall cost burden of AF in the USA. We therefore aimed to provide an up to date estimate of the overall per-patient costs of AF in managed care organizations across the USA.

METHODS

This retrospective cohort study used claims data from the Integrated Healthcare Information Systems National Managed Care Benchmark Database from January 2005 to December 2006. Patients included in the analysis were aged > or =20 years and had at least two outpatient AF-related claims without hospitalization, or a hospitalization with a primary or secondary discharge diagnosis of AF in 2005. AF-related inpatient and outpatient costs over 12 months from the initial outpatient claim or first hospitalization were examined. For secondary AF hospitalizations, incremental costs associated with AF were measured by comparing costs for patients with AF with a group of matched controls hospitalized without AF.

RESULTS

In total, 35,255 patients diagnosed as having AF (5008 with a primary AF diagnosis, 10,776 with a secondary AF diagnosis, 19,471 with outpatient-managed AF), and 20,571 controls without AF, were included in the analysis. Over 12 months, for primary AF hospitalization patients, inpatient costs were $11,306.53 and outpatient costs were $2826.78 (total $14,133.30) per patient. For hospitalized patients with secondary AF, incremental AF-related inpatient costs were $5181.19 and outpatient costs were $1376.33 (total $6557.52). For AF patients with outpatient management in 2005, 12-month AF-related costs were $2177.30 ($175.47 for AF hospitalizations in 2006 and $2001.85 for outpatient costs).

CONCLUSIONS

Overall costs of AF in the US managed care organizations are high. Costs are primarily due to inpatient expenses. Improved disease management strategies to reduce AF-related hospitalizations and decrease the overall cost burden of AF are needed.

Cost of Hospital Admission for Antiarrhythmic Drug Initiation in Atrial Fibrillation

Background

Initiation of some rhythm-control therapies for atrial fibrillation (AF) requires an inpatient hospital stay and telemetry monitoring, adding to the cost burden of AF. However, specific cost data for inpatient initiation of AF therapies are lacking.

Objective

To examine costs associated with initiating sotalol or dofetilide in the inpatient setting in the US.

Methods

This retrospective cohort study used data from billing/discharge records in the Premier Perspective Database for adults with a primary diagnosis of AF, hospitalized between January 2002 and September 2007. Patients had to have received 4 or more sotalol doses or 5 or more dofetilide doses starting within 2 days of admission (with ≥1 dose within 3 days of discharge). Patients admitted solely for AF drug initiation were identified by excluding patients who were admitted on an emergency basis, received care in the emergency department, or underwent major surgical procedures. The primary outcome was direct medical costs for in-hospital services during the stay.

Results

Among 7290 patients included in the analysis (4847 sotalol, 2443 dofetilide), mean total inpatient costs per patient were $3278 in the sotalol group and $3610 in the dofetilide group. The greatest costs were for room/board ($1874 sotalol, $1985 dofetilide) and cardiology/electrocardiograms ($394 sotalol, $443 dofetilide). Pharmacy costs were $230 and $201 per patient in the sotalol and dofetilide groups, respectively.

Conclusions

The admission of patients for in-hospital initiation of AF rhythm-control therapy represents a high cost burden in the US.

Leaving out control groups: an internal contrast analysis of gene expression profiles in atrial fibrillation patients--a systems biology approach to clinical categorization

Atrial fibrillation (AF) is a frequent chronic dysrythmia with an incidence that increases with age (>40). Because of its medical and socio-economic impacts it is expected to become an increasing burden on most health care systems. AF is a multi-factorial disease for which the identification of subtypes is warranted. Novel approaches based on the broad concepts of systems biology may overcome the blurred notion of normal and pathological phenotype, which is inherent to high throughput molecular arrays analysis. Here we apply an internal contrast algorithm on AF patient data with an analytical focus on potential entry pathways into the disease. We used a RMA (Robust Multichip Average) normalized Affymetrix micro-array data set from 10 AF patients (geo_accession #GSE2240). Four series of probes were selected based on physiopathogenic links with AF entryways: apoptosis (remodeling), MAP kinase (cell remodeling), OXPHOS (ability to sustain hemodynamic workload) and glycolysis (ischemia). Annotated probe lists were polled with Bioconductor packages in R (version 2.7.1). Genetic profile contrasts were analysed with hierarchical clustering and principal component analysis. The analysis revealed distinct patient groups for all probe sets. A substantial part (54% till 67%) of the variance is explained in the first 2 principal components. Genes in PC1/2 with high discriminatory value were selected and analyzed in detail. We aim for reliable molecular stratification of AF. We show that stratification is possible based on physiologically relevant gene sets. Genes with high contrast value are likely to give pathophysiological insight into permanent AF subtypes.