Cost–effectiveness of an insertable cardiac monitor to detect atrial fibrillation in patients with cryptogenic stroke

Abstract

Background: We assessed cost–effectiveness of insertable cardiac monitors (ICMs) in a US cryptogenic stroke population. Materials & methods: We modelled lifetime costs and quality-adjusted life years for three monitoring strategies post cryptogenic stroke: ICM starting immediately, ICM starting after Holter monitoring (delayed ICM) and standard of care involving intermittent ECG and Holter monitoring. Patient characteristics and detection efficacy were based on the CRYSTAL-AF trial. AF detection altered the modelled anticoagulation therapy and subsequent stroke and bleed risks. Results & conclusion: Immediate ICM was found to be cost-effective versus standard of care and cost-saving versus delayed ICM. Results were robust to sensitivity analyses. ICMs are a cost-effective diagnostic tool for the prevention of recurrent stroke in a US cryptogenic stroke population.

Longitudinal outcomes in cryptogenic stroke patients with and without long-term cardiac monitoring for atrial fibrillation

“…Finally, although our observations indicate that some stroke care pathways include a trial of ECMs before ICM (likely due in part to the higher upfront cost of the ICM device), recent cost-effectiveness analysis found this approach to be overall on average cost-additive compared to use of an ICM directly after CS, due to the low likelihood of diagnosis with an initial ECM. 21 These considerations may be important in jurisdictions with constrained health care resources, in which short- vs long-term clinical and economic implications must be weighed. Further research should focus on assessing economic and clinical implications of stroke monitoring pathways outside the United States.…”

Mobile Cardiac Outpatient Telemetry Patch vs Implantable Loop Recorder in Cryptogenic Stroke Patients in the US – Cost-Minimization Model

“…Other studies have examined the cost-effectiveness of ILR but have used a time horizon of over a lifetime, 24,[33][34][35] which is not relevant to our one-year timeframe. No prior modeling study has examined the costs of MCOT from the US perspective.…”

“…Values were derived from published studies identified through targeted literature review. All-cause mortality rates were derived from Sawyer et al 33 …”

“…Values were derived from published studies identified through targeted literature review. All-cause mortality rates were derived from Sawyer et al 33 Depending on the diagnostic performance of the allocated monitoring strategy, AF was subsequently detected, and patients were initiated on appropriate therapy (ie, OACs). If subsequent testing for AF was non-diagnostic, patients received aspirin alone (Figure 1).…”

“…Recurrent mild stroke 42% [33] Recurrent moderate stroke 26% [33] Recurrent severe stroke 10% [33] Recurrent fatal stroke/death 22% [33] Recurrent stroke in 1st year without OAC 15% [13,14] Recurrent stroke in 1st year with OAC 7.50% [24] Infection rate ILR…”