By Panos E Vardas
Rising healthcare costs have emphasised the need for evaluating modern therapies through a cost-effectiveness prism. Such a perspective is crucial for therapies available for the management of atrial fibrillation (AF), which represents the most prevalent rhythm abnormality in everyday clinical practice and is expected to reach alarming proportions in the near future. The latter phenomenon reflects the aging of the population and the increased incidence of predisposing or related heart diseases such as coronary artery disease, hypertension, valvular heart disease, heart failure and diabetes.
The management of AF imposes a considerable financial burden upon healthcare systems. For instance, the total annual cost for its treatment was estimated at US$6.65 billion in the United States in 2005 and more recently at €6.2 billion in five European countries, including Greece, Italy, Poland, Spain and The Netherlands.Similarly, the annual direct cost of AF in the UK has been reported to reach €655 million in 2000, which was equivalent to almost 1% of the NHS budget.
A few years back, the management of AF was mainly based on two pharmacological treatment strategies, namely rhythm and rate control, which according to scientific evidence have a similar effect on important health outcomes. About a decade ago, pulmonary vein isolation by means of catheter ablation became available and has steadily been gaining support ever since. Initially, it targeted the ectopic arrhythmogenic foci, but later it was redirected at anatomic and/or electrical pulmonary vein isolation.
On the basis of the encouraging results of large, randomised clinical trials, there is a trend to expand the existing indications and usage of ablation. Given the afore mentioned, regarding the epidemiology and the burden of AF and the difference in the profile of the two alternative treatment approaches, it is of interest to compare not only their effectiveness but also their cost and cost-effectiveness. Although, the existing evidence in this area is rather limited, it is certainly worth considering.
Specifically, a study in Canada that focused on patients with paroxysmal AF, estimated median total treatment cost with catheter ablation from $16,278 to $21,294, with an annual follow-up cost of $1,597 to $2,132, while the annual cost of medical therapy ranged between $4,176 and $5,060. Thus, there was cost equivalence after four years. In a similar manner, a study in France indicated that the cost of pharmacological treatment in 2001 was €1,590 per patient per year and the cost of ablation was €4,715 in the first year and €445 each year thereafter, which also indicates equivalence in about four years.
Furthermore, another recent study showed that atrial catheter ablation in comparison with medical rate therapy was not cost-effective in patients at low risk of stroke, but could be cost-effective in moderate risk patients. Specifically, the incremental cost per QALY gained with ablation over medical therapy at 2004 prices in the US was US$51,800 in the 65-year-old group at moderate risk, US$28,700 in the 55-year-old group at moderate risk, and US$98,900 in the 65-year-old group at low risk.
Catheter ablation is characterised by a high upfront cost in comparison to medical treatment for AF. However, in the light of the above evidence it can be argued that, under certain conditions, it represents an attractive alternative to pharmacotherapy in the long run, by decreasing subsequent long-term healthcare expenses. Nonetheless, more impressive long-term data pertaining to the effectiveness and cost-effectiveness of AF ablation are needed, to confirm expected benefits of this new therapy for patients.
Specifically, it appears that the benefits of the treatment relate to the age, stroke risk, and other important patient characteristics. The cost of the catheters and other materials and their utilisation patterns is important and matters are complicated by the rapid pace of medical technology evolution. The type of the implemented ablative method is also of primary importance and worthy of note that experts are constantly advancing the technique. Aside from other factors, the experience of the team performing the procedure appears to influence its success rate, effectiveness and complication rates.
Any assessment of this valuable, evolving and increasingly used technique in the management of AF patients must address the above issues. Hence, medical, technological, scientific, epidemiological and economic trends will make such assessment a challenge in the future, but also a necessity in order to maximise clinical and economic efficiency in the management of patients.