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Canadian Journal of Cardiology

Cost-Effectiveness of Left Atrial Appendage Closure for Stroke Prevention in Atrial Fibrillation Patients With Contraindications to Anticoagulation

  • Jacqueline Saw
    Correspondence
    Corresponding author: Dr Jacqueline Saw, Vancouver General Hospital, 2775 Laurel St, Level 9, Vancouver, British Columbia V5Z1M9, Canada. Tel.: +1-604-875-5547; fax: +1-604-875-5563.
    Affiliations
    Division of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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  • Maria C. Bennell
    Affiliations
    Schulich Heart Center, Division of Cardiology, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
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  • Sheldon M. Singh
    Affiliations
    Schulich Heart Center, Division of Cardiology, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
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  • Harindra C. Wijeysundera
    Affiliations
    Schulich Heart Center, Division of Cardiology, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada

    Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada

    Institute for Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, Ontario, Canada
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Published:February 23, 2016DOI:https://doi.org/10.1016/j.cjca.2016.02.056

      Abstract

      Background

      Percutaneous left atrial appendage closure (LAAC) is increasingly performed as an alternative to oral anticoagulation (OAC) in patients with nonvalvular atrial fibrillation (AF). We sought to evaluate the cost-effectiveness of treating OAC contraindicated patients with LAAC compared with aspirin alone.

      Methods

      A probabilistic patient-level Markov microsimulation model with a lifetime horizon was performed to assess the discounted lifetime costs, quality-adjusted life years, and incremental cost-effectiveness ratio of LAAC compared with aspirin for patients with AF with contraindications to OAC. Baseline characteristics were based on a published multicenter Canadian LAAC experience. Clinical events included stroke, bleeding, myocardial infarction, and procedure-related complications. Event rates for stroke and bleeding were based on the CHA2DS2-VASc and HAS-BLED scores. The relative efficacies of LAAC and aspirin, as well as utility scores, were obtained from the published literature. Canadian procedural and long-term costs were obtained from the Ontario Case Costing Initiative and the Ontario Ministry of Health and Long Term Care.

      Results

      Aspirin was less effective than LAAC (4.25 ± 0.53 vs 4.66 ± 0.34 quality-adjusted life years, respectively). The average discounted lifetime cost was CAD$30,748 ± 11,600 for LAAC and $38,974 ± 18,783 for aspirin. Thus, LAAC was dominant, being more effective and less expensive. Our results were robust with a relatively low degree of uncertainty, as LAAC was the preferred option in more than 90% of simulations at a willingness-to-pay threshold of $50,000.

      Conclusions

      LAAC is a novel stroke preventative therapy for nonvalvular AF and is a cost-effective alternative to aspirin in patients with contraindications to OAC.

      Résumé

      Introduction

      La fermeture percutanée de l’appendice auriculaire gauche (FAAG) est de plus en plus utilisée au lieu de l’anticoagulothérapie par voie orale (ACO) chez les patients présentant une fibrillation auriculaire (FA) non valvulaire. Nous avons cherché à évaluer la rentabilité de la FAAG comparativement à celle de l’aspirine en monothérapie lorsque l’ACO est contre-indiquée.

      Méthodes

      Un modèle probabiliste de microstimulation de Markov tenant compte d’un horizon temporel à vie au niveau des patients a été utilisé pour évaluer le coût actualisé la vie durant, les années de vie pondérées par la qualité et le rapport coût-efficacité différentiel de la FAAG comparativement à l’aspirine chez des patients atteints de FA présentant une contre-indication aux anticoagulants oraux. Les caractéristiques initiales ont été établies d’après des données multicentriques publiées sur l’expérience relative à la FAAG au Canada. Les événements cliniques incluaient l’accident vasculaire cérébral (AVC), l’hémorragie, l’infarctus du myocarde et les complications liées à l’intervention. Le taux d’AVC et d’hémorragies était fondé sur les scores aux échelles CHA2DS2-VASc et HAS-BLED. L’efficacité relative de la FAAG et de l’aspirine, de même que la cote d’utilité, ont été tirées des données publiées. Les coûts des interventions et des soins de longue durée proviennent de l’Ontario Case Costing Initiative et du ministère de la Santé et des Soins de longue durée de l’Ontario.

      Résultats

      L’aspirine était d’une efficacité moindre que la FAAG en ce qui a trait aux années de vie pondérées par la qualité (4,25 ± 0,53 vs 4,66 ± 0,34, respectivement). Le coût actualisé la vie durant s’est établi en moyenne à 30 748 $ CA ± 11 600 $ pour la FAAG et à 38 974 $ CA ± 18 783 $ pour l’aspirine. Les résultats favorisent donc la FAAG, qui s’est révélée plus efficace et moins chère. Nos résultats sont solides et comportent un degré relativement faible d’incertitude, puisque la FAAG représentait l’option privilégiée dans plus de 90 % des simulations, selon un seuil de volonté de payer de 50 000 $.

      Conclusions

      La FAAG est un traitement novateur dans la prévention des AVC chez les patients atteints de FA non valvulaire et constitue une option de rechange à l’aspirine rentable lorsque l’ACO est contre-indiquée.
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