Cost-Effectiveness of Catheter Ablation Versus Antiarrhythmic Drug Therapy in Atrial Fibrillation: The CABANA Randomized Clinical Trial

Abstract

Background: In the CABANA trial (Catheter Ablation vs Antiarrhythmic Drug Therapy for Atrial Fibrillation), catheter ablation did not significantly reduce the primary end point of death, disabling stroke, serious bleeding, or cardiac arrest compared with drug therapy by intention-to-treat, but did improve the quality of life and freedom from atrial fibrillation recurrence. In the heart failure subgroup, ablation improved both survival and quality of life. Cost-effectiveness was a prespecified CABANA secondary end point. Methods: Medical resource use data were collected for all CABANA patients (N=2204). Costs for hospital-based care were assigned using prospectively collected bills from US patients (n=1171); physician and medication costs were assigned using the Medicare Fee Schedule and National Average Drug Acquisition Costs, respectively. Extrapolated life expectancies were estimated using age-based survival models. Quality-of-life adjustments were based on EQ-5D–based utilities measured during the trial. The primary outcome was the incremental cost-effectiveness ratio, comparing ablation with drug therapy on the basis of intention-to-treat, and assessed from the US health care sector perspective. Results: Costs in the first 3 months averaged $20 794±SD 1069 higher with ablation compared with drug therapy. The cumulative within-trial 5-year cost difference was $19 245 (95% CI, $11 360–$27 170) and the lifetime mean cost difference was $15 516 (95% CI, –$2963 to $35,512) higher with ablation than with drug therapy. The drug therapy arm accrued an average of 12.5 life-years (LYs) and 10.7 quality-adjusted life-years (QALYs). For the ablation arm, the corresponding estimates were 12.6 LYs and 11.0 QALYs. The incremental cost-effectiveness ratio was $57 893 per QALY gained, with 75% of bootstrap replications yielding an incremental cost-effectiveness ratio < $100 000 per QALY gained. With no quality-of-life/utility adjustments, the incremental cost-effectiveness ratio was $183 318 per LY gained. Conclusions: Catheter ablation of atrial fibrillation was economically attractive compared with drug therapy in the CABANA Trial overall at present benchmarks for health care value in the United States on the basis of projected incremental QALYs but not LYs alone.

Cost-effectiveness of rhythm control strategy: Ablation versus antiarrhythmic drugs for treating atrial fibrillation in Korea based on real-world data

“…Despite advances in ablation and procedure techniques, costeffectiveness analyses of ablation-based rhythm control therapy have yielded heterogeneous conclusion that depend on the analysis model, parameters derived from the literature, and study population (17,18,(35)(36)(37)(38)(39). Recently, Chew et al (18) reported randomized trialbased economic evaluation results suggesting that catheter ablation of AF is economically attractive compared with drug therapy with an ICER of $57,893/QALY using the conventional WTP threshold of $100,000/QALY in the US. This study included detailed and comprehensive resource use data and quality-of-life adjustment factors.…”

“…It can be hypothesized that ablation-based rhythm control of AF is related to economic benefit. In some countries, economic assessments have reported a good cost-saving in ablation-based therapy compared with medical therapy ( 17 , 18 ). However, the economic evaluation of different rhythm control strategies for treating AF has not been conducted in the Republic of Korea.…”

Meta‑analysis of the efficacy and safety of nifekalant in the conversion of atrial fibrillation

“…However, due to the specific pathophysiological mechanism of AF, atrial arrhythmias still recur in 25-50% of patients following ablation, of which 21-38% are early recurrences ( 38 ). Some patients still have persistent AF following radiofrequency ablation, and although the traditional drug amiodarone and electrical resuscitation can be used to revert sinus rhythm, the time required for reversion and the need for complex electric shock operations are increasingly unable to meet the treatment needs of patients ( 3 , 39 ).…”

Economic Evaluation of Contact Force Catheter Ablation for Persistent Atrial Fibrillation in the United States

“…33 A recent cost-effectiveness study was conducted evaluating the data produced from the CABANA clinical trial. 34 This study looked at patients over a five-year time period and found higher costs in the ablation group. An important aspect to consider is that this study used intentto-treat cohorts despite very substantial cross-over in the CABANA study.…”