Cost-effectiveness analysis of left atrial appendage occlusion compared with pharmacological strategies for stroke prevention in atrial fibrillation

Abstract

BackgroundTranscatheter left atrial appendage occlusion (LAAO) is a promising therapy for stroke prophylaxis in non-valvular atrial fibrillation (NVAF) but its cost-effectiveness remains understudied. This study evaluated the cost-effectiveness of LAAO for stroke prophylaxis in NVAF.MethodsA Markov decision analytic model was used to compare the cost-effectiveness of LAAO with 7 pharmacological strategies: aspirin alone, clopidogrel plus aspirin, warfarin, dabigatran 110 mg, dabigatran 150 mg, apixaban, and rivaroxaban. Outcome measures included quality-adjusted life years (QALYs), lifetime costs and incremental cost-effectiveness ratios (ICERs). Base-case data were derived from ACTIVE, RE-LY, ARISTOTLE, ROCKET-AF, PROTECT-AF and PREVAIL trials. One-way sensitivity analysis varied by CHADS2 score, HAS-BLED score, time horizons, and LAAO costs; and probabilistic sensitivity analysis using 10,000 Monte Carlo simulations was conducted to assess parameter uncertainty.ResultsLAAO was considered cost-effective compared with aspirin, clopidogrel plus aspirin, and warfarin, with ICER of US$5,115, $2,447, and $6,298 per QALY gained, respectively. LAAO was dominant (i.e. less costly but more effective) compared to other strategies. Sensitivity analysis demonstrated favorable ICERs of LAAO against other strategies in varied CHADS2 score, HAS-BLED score, time horizons (5 to 15 years) and LAAO costs. LAAO was cost-effective in 86.24 % of 10,000 simulations using a threshold of US$50,000/QALY.ConclusionsTranscatheter LAAO is cost-effective for prevention of stroke in NVAF compared with 7 pharmacological strategies.Condensed abstractThe transcatheter left atrial appendage occlusion (LAAO) is considered cost-effective against the standard 7 oral pharmacological strategies including acetylsalicylic acid (ASA) alone, clopidogrel plus ASA, warfarin, dabigatran 110 mg, dabigatran 150 mg, apixaban, and rivaroxaban for stroke prophylaxis in non-valvular atrial fibrillation management.

Cost-effectiveness of left atrial appendage closure for stroke prevention in atrial fibrillation: a systematic review appraising the methodological quality

“…Recommendations specify a score greater than 1 for males and greater than 2 for females [ 4 ]. Two studies we reviewed did not specify the CHADS 2 VASc score for their base-case populations [ 21 , 24 ]. Freeman et al [ 23 ] considered a score greater than 1, regardless of gender, in the base case population.…”

“…In six of these evaluations (67%), LAAC had a more than 50% probability of being cost-effective compared to warfarin [ 19 – 21 , 23 , 26 , 27 ]. In the majority of evaluations with dabigatran (6 out of 8 studies) [ 20 , 21 , 23 , 24 , 27 ], apixaban (3 out of 5 studies) [ 11 , 20 – 22 , 24 ], and rivaroxaban (2 out of 3 studies) [ 11 , 21 , 24 ], LAAC emerged as the cost-effective intervention in 50% or more of the times. [ 20 , 21 , 23 , 24 , 27 ].…”

Review of cost-effectiveness of antithrombotic alternatives in patients with atrial fibrillation

“…This review included 18 articles (Table 1) [11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28] assessed according to authors, year of publication, study design, country of publication, therapeutic alternatives versus cost, and principal conclusions. In the cost analysis, the main currencies of circulation were the euro [11][12][13][19][20][21][22][23] and the dollar [14][15][16][17][18][20][21][22]24,25 .…”

Comparison of three left atrial appendage occlusion devices for stroke prevention in patients with non-valvular atrial fibrillation: a single-centre seven-year experience with WATCHMAN, AMPLATZER Cardiac Plug/Amulet, LAmbre

“…LAAO obviates the need for long-term anticoagulation (except in a small number of patients with persistent device-related thrombus) and hence the risk of bleeding and also stroke from subtherapeutic INR. Although there are no direct comparisons between LAAO and NOAC, our group recently published a study using the Markov decision analytic model to compare the cost-effectiveness of LAAO with seven pharmacological strategies including aspirin alone, clopidogrel plus aspirin, warfarin, dabigatran (110 mg and 150 mg), apixaban and rivaroxaban from a Hong Kong healthcare provider perspective 14 . We found that LAAO was considered cost-effective compared to warfarin, with an incremental cost-effectiveness ratio (ICER) of USD 6,298 per quality-adjusted life years (QALY) gained; LAAO was considered dominant (i.e., less costly and more effective) compared to all three NOAC.…”