Comparative Clinical Effectiveness of Population-Based Atrial Fibrillation Screening Using Contemporary Modalities: A Decision-Analytic Model

Accuracy of Artificial Intelligence-Based Technologies for the Diagnosis of Atrial Fibrillation: A Systematic Review and Meta-Analysis

Atrial fibrillation (AF) is the most common arrhythmia with a high burden of morbidity including impaired quality of life and increased risk of thromboembolism. Early detection and management of AF could prevent thromboembolic events. Artificial intelligence (AI)--based methods in healthcare are developing quickly and can be proved as valuable for the detection of atrial fibrillation. In this metanalysis, we aim to review the diagnostic accuracy of AI-based methods for the diagnosis of atrial fibrillation. A predetermined search strategy was applied on four databases, the PubMed on 31 August 2022, the Google Scholar and Cochrane Library on 3 September 2022, and the Embase on 15 October 2022. The identified studies were screened by two independent investigators. Studies assessing the diagnostic accuracy of AI-based devices for the detection of AF in adults against a gold standard were selected. Qualitative and quantitative synthesis to calculate the pooled sensitivity and specificity was performed, and the QUADAS-2 tool was used for the risk of bias and applicability assessment. We screened 14,770 studies, from which 31 were eligible and included. All were diagnostic accuracy studies with case-control or cohort design. The main technologies used were: (a) photoplethysmography (PPG) with pooled sensitivity 95.1% and specificity 96.2%, and (b) single-lead ECG with pooled sensitivity 92.3% and specificity 96.2%. In the PPG group, 0% to 43.2% of the tracings could not be classified using the AI algorithm as AF or not, and in the single-lead ECG group, this figure fluctuated between 0% and 38%. Our analysis showed that AI-based methods for the diagnosis of atrial fibrillation have high sensitivity and specificity for the detection of AF. Further studies should examine whether utilization of these methods could improve clinical outcomes.

Reimbursement practices for use of digital devices in atrial fibrillation and other arrhythmias: a European Heart Rhythm Association survey

AIMS

Since digital devices are increasingly used in cardiology for assessing cardiac rhythm and detecting arrhythmias, especially atrial fibrillation (AF), our aim was to evaluate the expectations and opinions of healthcare professionals in Europe on reimbursement policies for the use of digital devices (including wearables) in AF and other arrhythmias.

METHODS AND RESULTS

An anonymous survey was proposed through announcements on the European Heart Rhythm Association website, social media channels, and mail newsletter. Two hundred and seventeen healthcare professionals participated in the survey: 32.7%, reported regular use of digital devices, 45.2% reported that they sometimes use these tools, 18.6% that they do not use but would like to. Only a minority (3.5%) reported a lack of trust in digital devices. The survey highlighted a general propensity to provide medical consultation for suspected AF or other arrhythmias detected by a consumer-initiated use of digital devices, even if time constraints and reimbursement availability emerged as important elements. More than 85% of respondents agreed that reimbursement should be applied for clinical use of digital devices, also in different settings such as post-stroke, post-cardioversion, post-ablation, and in patients with palpitations or syncope. Finally, 73.6% of respondents confirmed a lack of reimbursement fees in their country for physicians' consultations (tracings interpretation) related to digital devices.

CONCLUSIONS

Digital devices, including wearables, are increasingly and widely used for assessing cardiac rhythm and detecting AF, but a definition of reimbursement policies for physicians' consultations is needed.

Cost-effectiveness of Screening for Atrial Fibrillation Using Wearable Devices

Question

Is population-based atrial fibrillation (AF) screening using wearable devices cost-effective?

Findings

In this economic evaluation of 30 million simulated individuals with an age, sex, and comorbidity profile matching the US population aged 65 years or older, AF screening using wearable devices was cost-effective, with the overall preferred strategy identified as wearable photoplethysmography, followed conditionally by wearable electrocardiography with patch monitor confirmation (incremental cost-effectiveness ratio, $57 894 per quality-adjusted life-year). The cost-effectiveness of screening was consistent across multiple scenarios, including strata of sex, screening at earlier ages, and with variation in the association of anticoagulation with risk of stroke associated with screening-detected AF.

Meaning

This study suggests that contemporary AF screening using wearable devices may be cost-effective.

Importance

Undiagnosed atrial fibrillation (AF) is an important cause of stroke. Screening for AF using wrist-worn wearable devices may prevent strokes, but their cost-effectiveness is unknown.

Objective

To evaluate the cost-effectiveness of contemporary AF screening strategies, particularly wrist-worn wearable devices.

Design, Setting, and Participants

This economic evaluation used a microsimulation decision-analytic model and was conducted from September 8, 2020, to May 23, 2022, comprising 30 million simulated individuals with an age, sex, and comorbidity profile matching the US population aged 65 years or older.

Interventions

Eight AF screening strategies, with 6 using wrist-worn wearable devices (watch or band photoplethysmography, with or without watch or band electrocardiography) and 2 using traditional modalities (ie, pulse palpation and 12-lead electrocardiogram) vs no screening.

Main Outcomes and Measures

The primary outcome was the incremental cost-effectiveness ratio, defined as US dollars per quality-adjusted life-year (QALY). Secondary measures included rates of stroke and major bleeding.

Results

In the base case analysis of this model, the mean (SD) age was 72.5 (7.5) years, and 50% of the individuals were women. All 6 screening strategies using wrist-worn wearable devices were estimated to be more effective than no screening (range of QALYs gained vs no screening, 226-957 per 100 000 individuals) and were associated with greater relative benefit than screening using traditional modalities (range of QALYs gained vs no screening, −116 to 93 per 100 000 individuals). Compared with no screening, screening using wrist-worn wearable devices was associated with a reduction in stroke incidence by 20 to 23 per 100 000 person-years but an increase in major bleeding by 20 to 44 per 100 000 person-years. The overall preferred strategy was wearable photoplethysmography, followed conditionally by wearable electrocardiography with patch monitor confirmation, which had an incremental cost-effectiveness ratio of $57 894 per QALY, meeting the acceptability threshold of $100 000 per QALY. The cost-effectiveness of screening was consistent across multiple scenarios, including strata of sex, screening at earlier ages (eg, ≥50 years), and with variation in the association of anticoagulation with risk of stroke in the setting of screening-detected AF.

Conclusions and Relevance

This economic evaluation of AF screening using a microsimulation decision-analytic model suggests that screening using wearable devices is cost-effective compared with either no screening or AF screening using traditional methods.