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Research Article
30 June 2023

Clinical and economic outcomes associated with use of anti-arrhythmic drugs versus ablation in atrial fibrillation

Authors: Jennifer Ken-Opurum [email protected], Sesha SS Srinivas, Seojin Park, Scott Charland, Andrew Revel, and Ronald PreblickAuthor Info & Affiliations
Volume 12, Number 8
https://doi.org/10.57264/cer-2023-0065
PDFFormats

Abstract

Aim: To evaluate the clinical and economic impact of antiarrhythmic drugs (AADs) compared with ablation both as individual treatments and as combination therapy without/with considering the order of treatment among patients with atrial fibrillation (AFib). Materials & methods: A budget impact model over a one-year time horizon was developed to assess the economic impact of AADs (amiodarone, dofetilide, dronedarone, flecainide, propafenone, sotalol, and as a group) versus ablation across three scenarios: direct comparisons of individual treatments, non-temporal combinations, and temporal combinations. The economic analysis was conducted in accordance with CHEERS guidance as per current model objectives. Results are reported as costs per patient per year (PPPY). The impact of individual parameters was evaluated using one-way sensitivity analysis (OWSA). Results: In direct comparisons, ablation had the highest annual medication/procedure cost ($29,432), followed by dofetilide ($7661), dronedarone ($6451), sotalol ($4552), propafenone ($3044), flecainide ($2563), and amiodarone ($2538). Flecainide had the highest costs for long-term clinical outcomes ($22,964), followed by dofetilide ($17,462), sotalol ($15,030), amiodarone ($12,450), dronedarone ($10,424), propafenone ($7678) and ablation ($9948). In the non-temporal scenario, total costs incurred for AADs (group) + ablation ($17,278) were lower compared with ablation alone ($39,380). In the temporal scenario, AADs (group) before ablation resulted in PPPY cost savings of ($22,858) compared with AADs (group) after ablation ($19,958). Key factors in OWSA were ablation costs, the proportion of patients having reablation, and withdrawal due to adverse events. Conclusion: Utilization of AADs as individual treatment or in combination with ablation demonstrated comparable clinical benefits along with costs savings in patients with AFib.

Plain language summary

What is this article about?

Atrial fibrillation (AFib) is the most common type of heart rhythm disorder in which the heart beats too slowly, too fast, or in an irregular way. During AFib, the upper and lower chambers of the heart beat out of sync, causing blood flow to be ineffective. Symptoms of AFib include palpitations, lightheadedness, shortness of breath, and fatigue. Guidelines recommend rate control and rhythm control as important treatments for the management of AFib. Rhythm control strategies including antiarrhythmic drugs (AADs) and ablation are promising interventions for maintaining sinus rhythm.
This study assessed the economic impact of AAD use versus ablation in patients with AFib from a US payer's perspective. Three different scenarios were compared: direct comparisons of individual treatments, non-temporal combinations (scenarios where order of treatments was not considered), and temporal combinations (scenarios where order of treatments was considered).

What were the results?

In the direct comparison of AADs versus ablation, per patient per year (PPPY) costs across AADs were 35%–73% lower compared with ablation, mainly due to higher procedural costs of ablation. In the non-temporal scenario, PPPY costs for AADs used in combination with ablation were 44% lower compared with ablation alone. In the temporal scenario, AADs placed before ablation yielded 87% cost savings compared with AADs placed post-ablation, largely due to improved clinical outcomes associated with AAD use and high costs of ablation.

What do the results mean?

Overall, use of AADs alone or in combination with ablation resulted in comparable clinical benefits with lower costs. Decision-makers can use these findings to inform decisions about economical treatment alternatives available for patients with AFib.

Supplementary Material

File (supplementary tables.docx)

References

Papers of special note have been highlighted as: • of interest; •• of considerable interest
1.
Chugh SS, Havmoeller R, Narayanan K et al. Worldwide epidemiology of atrial fibrillation: a Global Burden of Disease 2010 Study. Circulation 129(8), 837–847 (2014).
PubMed
Google Scholar
2.
Benjamin EJ, Wolf PA, D'Agostino RB, Silbershatz H, Kannel WB, Levy D. Impact of atrial fibrillation on the risk of death: the Framingham Heart Study. Circulation 98(10), 946–952 (1998).
PubMed
Google Scholar
3.
Kalantarian S, Ay H, Gollub RL et al. Association between atrial fibrillation and silent cerebral infarctions: a systematic review and meta-analysis. Ann. Intern. Med. 161(9), 650–658 (2014).
PubMed
Google Scholar
4.
Centers for Disease Control and Prevention. Atrial Fibrillation. www.cdc.gov/heartdisease/atrial_fibrillation.htm. (2023).
Google Scholar
5.
Benjamin EJ, Muntner P, Alonso A et al. Heart disease and stroke statistics-2019 update: a report from the American Heart Association. Circulation 139(10), e56–e528 (2019).
PubMed
Google Scholar
6.
Tsao CW, Aday AW, Almarzooq ZI et al. Heart disease and stroke statistics-2022 update: a report from the American Heart Association. Circulation 145(8), e153–e639 (2022).
PubMed
Google Scholar
8.
Rienstra M, Lubitz SA, Mahida S et al. Symptoms and functional status of patients with atrial fibrillation: state of the art and future research opportunities. Circulation 125(23), 2933–2943 (2012).
PubMed
Google Scholar
9.
Coyne KS, Paramore C, Grandy S, Mercader M, Reynolds M, Zimetbaum P. Assessing the direct costs of treating nonvalvular atrial fibrillation in the United States. Value Health 9(5), 348–356 (2006).
PubMed
Google Scholar
10.
Abugroun A, Taha A, Abdel-Rahman M, Volgman AS. Economic impact of atrial fibrillation on hospitalization outcomes of acute heart failure in the United States. Am. J. Cardiol. 138, 124–127 (2021).
PubMed
Google Scholar
11.
Kim MH, Johnston SS, Chu BC, Dalal MR, Schulman KL. Estimation of total incremental health care costs in patients with atrial fibrillation in the United States. Circ. Cardiovasc. Qual. Outcomes 4(3), 313–320 (2011).
PubMed
Google Scholar
12.
Proietti M, Romiti GF, Olshansky B, Lane DA, Lip GYH. Comprehensive management with the ABC (Atrial Fibrillation Better Care) Pathway in clinically complex patients with atrial fibrillation: a post hoc ancillary analysis from the AFFIRM Trial. J. Am. Heart Assoc. 9(10), e014932 (2020).
PubMed
Google Scholar
13.
Lip GYH. The ABC pathway: an integrated approach to improve AF management. Nat. Rev. Cardiol. 14(11), 627–628 (2017).
PubMed
Google Scholar
14.
Hohnloser SH, Crijns HJ, van Eickels M et al. Effect of dronedarone on cardiovascular events in atrial fibrillation. N. Engl. J. Med. 360(7), 668–678 (2009).
PubMed
Google Scholar
•• This study helped in understanding safety of dronedarone.
15.
Kirchhof P, Camm AJ, Goette A et al. Early rhythm-control therapy in patients with atrial fibrillation. N. Engl. J. Med. 383(14), 1305–1316 (2020).
PubMed
Google Scholar
•• This study provided insight to understand the decision-making behavior for rhythm-control therapy in patients with early AFib.
16.
Andrade JG, Wells GA, Deyell MW et al. Cryoablation or drug therapy for initial treatment of atrial fibrillation. N. Engl. J. Med. 384(4), 305–315 (2021).
PubMed
Google Scholar
17.
Kuck KH, Lebedev DS, Mikhaylov EN et al. Catheter ablation or medical therapy to delay progression of atrial fibrillation: the randomized controlled atrial fibrillation progression trial (ATTEST). Europace 23(3), 362–369 (2021).
PubMed
Google Scholar
18.
Valembois L, Audureau E, Takeda A, Jarzebowski W, Belmin J, Lafuente-Lafuente C. Antiarrhythmics for maintaining sinus rhythm after cardioversion of atrial fibrillation. Cochrane Database Syst. Rev. 9(9), (2019).
Crossref
PubMed
Google Scholar
•• This study helped in calculating the risks of long-term clinical outcomes (LTCOs) for antiarrhythmic drugs (AADs), which provided a base to compare dronedarone with other AADs in scenario analysis.
19.
January CT, Wann LS, Alpert JS et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J. Am. Coll. Cardiol. 64(21), e1–e76 (2014).
PubMed
Google Scholar
• This study provided recommendations for the management of patients with atrial fibrillation (AFib).
20.
Marrouche NF, Brachmann J, Andresen D et al. Catheter ablation for atrial fibrillation with heart failure. N. Engl. J. Med. 378(5), 417–427 (2018).
PubMed
Google Scholar
21.
Packer DL, Piccini JP, Monahan KH et al. Ablation versus drug therapy for atrial fibrillation in heart failure: results from the CABANA Trial. Circulation 143(14), 1377–1390 (2021).
PubMed
Google Scholar
• This study provided insights on the benefits of catheter ablation compared to drug therapies in patients with symptomatic AFib.
22.
Wazni OM, Dandamudi G, Sood N et al. Cryoballoon ablation as initial therapy for atrial fibrillation. N. Engl. J. Med. 384(4), 316–324 (2021).
PubMed
Google Scholar
23.
Hindricks G, Potpara T, Dagres N et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur. Heart J. 42(5), 373–498 (2021).
PubMed
Google Scholar
•• This guideline provided insights on the recommendations to treat AFib.
24.
Wu L, Narasimhan B, Ho KS, Zheng Y, Shah AN, Kantharia BK. Safety and complications of catheter ablation for atrial fibrillation: predictors of complications from an updated analysis the National Inpatient Database. J. Cardiovasc. Electrophysiol. 32(4), 1024–1034 (2021).
PubMed
Google Scholar
•• This study provided insights on the safety and predictors of ablation procedural complications.
25.
Nyong J, Amit G, Adler AJ et al. Efficacy and safety of ablation for people with non-paroxysmal atrial fibrillation. Cochrane Database Syst. Rev. 11(11), (2016).
Crossref
PubMed
Google Scholar
26.
Husereau D, Drummond M, Augustovski F et al. Consolidated Health Economic Evaluation Reporting Standards 2022 (CHEERS 2022) Statement: Updated Reporting Guidance for Health Economic Evaluations. CHEERS 2022 ISPOR Good Research Practices Task Force.
Google Scholar
27.
Lei M, Wu L, Terrar DA, Huang CL. Modernized classification of cardiac antiarrhythmic drugs. Circulation 138(17), 1879–1896 (2018).
PubMed
Google Scholar
28.
Freemantle N, Lafuente-Lafuente C, Mitchell S, Eckert L, Reynolds M. Mixed treatment comparison of dronedarone, amiodarone, sotalol, flecainide, and propafenone, for the management of atrial fibrillation. Europace 13(3), 329–345 (2011).
PubMed
Google Scholar
29.
Consumer Price Index Inflation Calculator. (bls.gov), (2021). www.bls.gov/data/inflation_calculator.htm
Google Scholar
30.
Reynolds MR, Zimetbaum P, Josephson ME, Ellis E, Danilov T, Cohen DJ. Cost-effectiveness of radiofrequency catheter ablation compared with antiarrhythmic drug therapy for paroxysmal atrial fibrillation. Circ. Arrhythm Electrophysiol. 2(4), 362–369 (2009).
PubMed
Google Scholar
31.
Bruggenjurgen B, Kohler S, Ezzat N, Reinhold T, Willich SN. Cost effectiveness of antiarrhythmic medications in patients suffering from atrial fibrillation. Pharmacoeconomics 31(3), 195–213 (2013).
PubMed
Google Scholar
32.
Podrid PJ, Kowey PR, Frishman WH et al. Comparative cost-effectiveness analysis of quinidine, procainamide and mexiletine. Am. J. Cardiol. 68(17), 1662–1667 (1991).
PubMed
Google Scholar
33.
Anderson LH, Black EJ, Civello KC, Martinson MS, Kress DC. Cost-effectiveness of the convergent procedure and catheter ablation for non-paroxysmal atrial fibrillation. J. Med. Econ. 17(7), 481–491 (2014).
PubMed
Google Scholar
34.
Sultan A, Luker J, Andresen D et al. Predictors of atrial fibrillation recurrence after catheter ablation: data from the German Ablation Registry. Sci. Rep. 7(1), (2017).
Crossref
Google Scholar
35.
Szegedi N, Széplaki G, Herczeg S et al. Repeat procedure is a new independent predictor of complications of atrial fibrillation ablation. Europace. 21(5), 732–737 (2019).
PubMed
Google Scholar
37.
Whaley CM, Briscombe B, Kerber R, O'Neill B, Kofner A. Prices Paid to Hospitals by Private Health Plans: Findings from Round 4 of an Employer-Led Transparency Initiative. Rand Health Q. 10(1), 5 (2022).
PubMed
Google Scholar
38.
Numminen A, Penttila T, Arola O et al. Treatment success and its predictors as well as the complications of catheter ablation for atrial fibrillation in a high-volume centre. J. Interv. Card. Electrophysiol. 63(2), 357–367 (2022).
PubMed
Google Scholar
39.
Center for Medicare & Medicaid Services. Physician Fee Schedule Look-Up Tool (HCPCS code 99214). www.cms.gov/medicare/physician-fee-schedule/search?Y=0&T=4&HT=0&CT=3&H1=99214&M=5. (2021).
Google Scholar
40.
Kim MH, Klingman D, Lin J, Pathak P, Battleman DS. Cost of hospital admission for antiarrhythmic drug initiation in atrial fibrillation. Ann. Pharmacother. 43(5), 840–848 (2009).
PubMed
Google Scholar
41.
Dronedarone label (fda.gov). MULTAQ® (dronedarone) tablets, for oral use Prescribing Information. www.accessdata.fda.gov/drugsatfda_docs/label/2011/022425s007lbl.pdf (2021).
Google Scholar
43.
Sotalol label (fda.gov). Sotalol IV (sotalol hydrochloride injection 10mL vial [15mg/mL]). www.accessdata.fda.gov/drugsatfda_docs/label/2020/022306s005lblrpl.pdf (2021).
Google Scholar
44.
Flecainide: Package Insert (Drugs.com). Flecainide: Package Insert / Prescribing Information. www.drugs.com/pro/flecainide.html (2021).
Google Scholar
46.
MULTAQ Savings Card Program. MULTAQ® (dronedarone) Tablet 400 mg. www.multaq.com/savings-and-support/multaq-savings-card-program. (2023).
Google Scholar
47.
Ruzieh M, Moroi MK, Aboujamous NM et al. Meta-analysis comparing the relative risk of adverse events for amiodarone versus placebo. Am. J. Cardiol. 124(12), 1889–1893 (2019).
PubMed
Google Scholar
48.
Mason JW. Amiodarone. N. Engl. J. Med. 316(8), 455–466 (1987).
PubMed
Google Scholar
49.
Calkins H, Hindricks G, Cappato R et al. 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation. Europace 20(1), e1–e160 (2017).
Google Scholar
50.
Gunawardena RF, Furniss SS, Shepherd E, Santarpia G, Lord SW, Bourke JP. Outcomes following catheter ablation of atrial fibrillation in the UK: a single-centre cohort analysis. Brit. J. Cardiol. 17, 271–276 (2010).
Google Scholar
51.
Vamos M, Calkins H, Kowey PR et al. Efficacy and safety of dronedarone in patients with a prior ablation for atrial fibrillation/flutter: insights from the ATHENA study. Clin. Cardiol. 43(3), 291–297 (2020).
PubMed
Google Scholar
52.
Ken-Opurum J, Srinivas SS, Vadagam P et al. A value-based budget impact model for dronedarone compared with other rhythm control strategies. J. Comp. Eff. Res. 12(4), e220196 (2023).
PubMed
Google Scholar
•• Results from this study helped in informing the pricing and formulary decisions related to dronedarone.
53.
Asad ZUA, Yousif A, Khan MS, Al-Khatib SM, Stavrakis S. Catheter ablation versus medical therapy for atrial fibrillation: a systematic review and meta-analysis of randomized controlled trials. Circ. Arrhythm Electrophysiol. 12(9), e007414 (2019).
PubMed
Google Scholar
54.
Blomstrom-Lundqvist C, Gizurarson S, Schwieler J et al. Effect of catheter ablation vs antiarrhythmic medication on quality of life in patients with atrial fibrillation: the CAPTAF randomized clinical trial. JAMA 321(11), 1059–1068 (2019).
PubMed
Google Scholar
55.
Packer DL, Mark DB, Robb RA et al. Effect of catheter ablation vs antiarrhythmic drug therapy on mortality, stroke, bleeding, and cardiac arrest among patients with atrial fibrillation: the CABANA randomized clinical trial. JAMA 321(13), 1261–1274 (2019).
PubMed
Google Scholar
56.
Mark DB, Anstrom KJ, Sheng S et al. Effect of catheter ablation vs medical therapy on quality of life among patients with atrial fibrillation: the CABANA randomized clinical trial. JAMA 321(13), 1275–1285 (2019).
PubMed
Google Scholar
57.
The SF-36v2® Health Survey. Measure functional health and well-being from the patient's point of view with the SF-36v2® Health Survey. www.qualitymetric.com/health-surveys/the-sf-36v2-health-survey/. (2023).
Google Scholar
58.
EQ-5D. EUROQOL INSTRUMENTS. https://euroqol.org/ (2023).
Google Scholar
59.
Kibert JL, Franck JB, Maltese Dietrich N, Quffa LH, Franck AJ. Impact of a pharmacy-cardiology collaborative management program during initiation of antiarrhythmic drugs. Clin. Pharm. Res. Rep. 3(1), 30–35 (2020).
Google Scholar
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