RESUMEN
BACKGROUND: Same day discharge (SDD) following atrial fibrillation (AF) ablation procedure has emerged as routine practice, and primarily driven by operator discretion. However, the impacts of SDD on clinical outcomes, healthcare system costs, and patient reported outcomes (PROs) have not been systematically studied. METHODS: We retrospectively analyzed patients undergoing routine AF ablation procedures with SDD versus overnight observation (NSDD). After propensity adjustment we compared postprocedure adverse events (AEs), healthcare system costs, and changes in PROs. RESULTS: We identified 310 cases, with 159 undergoing SDD and 151 staying at least one midnight in the hospital (NSDD). Compared with NSDD, SDD patients were similar age (mean 64 vs. 66, p = 0.3), sex (26% female vs. 27%, p = 0.8), and with lower mean CHADS2-VA2Sc scores (2.0 vs. 2.7; p < 0.011). The primary outcome of AEs was noninferior in SDD versus NSDD patients (odds ratio 0.45, 95% confidence interval 0.21-0.99; noninferiority margin of 10%). There were also no differences in overall cost to the healthcare system between SDD and NSDD (p = 0.11). PROs numerically favored SDD (p = NS for all scores). CONCLUSIONS: Physician selection for SDD appears at least as safe as NSDD with respect to clinical outcomes and SDD is not significantly less costly to the health system. There is a trend towards more favorable, general PROs among SDD patients. Routine SDD should be strongly considered for patients undergoing routine AF ablation procedures.
Asunto(s)
Fibrilación Atrial , Ablación por Catéter , Alta del Paciente , Medición de Resultados Informados por el Paciente , Humanos , Fibrilación Atrial/cirugía , Fibrilación Atrial/economía , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/fisiopatología , Femenino , Masculino , Estudios Retrospectivos , Ablación por Catéter/economía , Ablación por Catéter/efectos adversos , Persona de Mediana Edad , Anciano , Resultado del Tratamiento , Factores de Tiempo , Alta del Paciente/economía , Costos de Hospital , Factores de Riesgo , Análisis Costo-Beneficio , Tiempo de Internación/economía , Procedimientos Quirúrgicos Ambulatorios/economía , Procedimientos Quirúrgicos Ambulatorios/efectos adversosRESUMEN
BACKGROUND AND AIMS: Cardiac ablation is a well-established method for treating atrial fibrillation (AF). Pulsed field ablation (PFA) is a non-thermal therapeutic alternative to radiofrequency ablation (RFA) and cryoballoon ablation (CRYO). PFA uses high-voltage electric pulses to target cells. The present analysis aims to quantify the costs, outcomes, and resources associated with these three ablation strategies for paroxysmal AF. METHODS: Real-world clinical data were prospectively collected during index hospitalization by three European medical centers (Belgium, Germany, the Netherlands) specialized in cardiac ablation. These data included procedure times (pre-procedural, skin-to-skin and post-procedural), resource use, and staff burden. Data regarding complications associated with each of the three treatment options and redo procedures were extracted from the literature. Costs were collected from hospital economic formularies and published cost databases. A cost-consequence model from the hospital perspective was built to estimate the impact of the three treatment options in terms of effectiveness and costs. RESULTS: Across the three centers, N = 91 patients were included over a period of 12 months. A significant difference was seen in pre-procedural time (mean ± SD, PFA: 13.6 ± 3.7 min, CRYO: 18.8 ± 6.6 min, RFA: 20.4 ± 6.4 min; p < .001). Procedural time (skin-to-skin) was also different across alternatives (PFA: 50.9 ± 22.4 min, CRYO: 74.5 ± 24.5 min, RFA: 140.2 ± 82.4 min; p < .0001). The model reported an overall cost of 216,535 per 100 patients treated with PFA, 301,510 per 100 patients treated with CRYO and 346,594 per 100 patients treated with RFA. Overall, the cumulative savings associated with PFA (excluding kit costs) were 850 and 1,301 per patient compared to CRYO and RFA, respectively. CONCLUSION: PFA demonstrated shorter procedure time compared to CRYO and RFA. Model estimates indicate that these time savings result in cost savings for hospitals and reduce outlay on redo procedures. Clinical practice in individual hospitals varies and may impact the ability to transfer the results of this analysis to other settings.
Asunto(s)
Fibrilación Atrial , Ablación por Catéter , Análisis Costo-Beneficio , Humanos , Fibrilación Atrial/cirugía , Fibrilación Atrial/economía , Masculino , Femenino , Persona de Mediana Edad , Ablación por Catéter/economía , Ablación por Catéter/métodos , Anciano , Tempo Operativo , Estudios Prospectivos , Europa (Continente) , Criocirugía/economía , Criocirugía/métodos , Complicaciones Posoperatorias/economía , Recursos en Salud/estadística & datos numéricos , Recursos en Salud/economíaRESUMEN
BACKGROUND: With the exponential growth of catheter ablation for atrial fibrillation (AF), there is increasing interest in associated health care costs. Pulsed field ablation (PFA) using a single-shot pentaspline multielectrode catheter has been shown to be safe and effective for AF ablation, but its cost efficiency compared to conventional thermal ablation modalities (cryoballoon [CB] or radiofrequency [RF]) has not been evaluated. OBJECTIVE: The purpose of this study was to compare cost, efficiency, effectiveness, and safety between PFA, CB, and RF for AF ablation. METHODS: We studied 707 consecutive patients (PFA: 208 [46.0%]; CB: 325 [29.4%]; RF: 174 [24.6%]) undergoing first-time AF ablation. Individual procedural costs were calculated, including equipment, laboratory use, and hospital stay, and compared between ablation modalities, as were effectiveness and safety. RESULTS: Skin-to-skin times and catheter laboratory times were significantly shorter with PFA (68 and 102 minutes, respectively) than with CB (91 and 122 minutes) and RF (89 and 123 minutes) (P < .001). General anesthesia use differed across modalities (PFA 100%; CB 10.2%; RF 61.5%) (P < .001). Major complications occurred in 1% of cases, with no significant differences between modalities. Shorter procedural times resulted in lower staffing and laboratory costs with PFA, but these savings were offset by substantially higher equipment costs, resulting in higher overall median costs with PFA (£10,010) than with CB (£8106) and RF (£8949) (P < .001). CONCLUSION: In this contemporary real-world study of the 3 major AF ablation modalities used concurrently, PFA had shorter skin-to-skin and catheter laboratory times than did CB and RF, with similarly low rates of complications. However, PFA procedures were considerably more expensive, largely because of higher equipment cost.
Asunto(s)
Fibrilación Atrial , Ablación por Catéter , Fibrilación Atrial/cirugía , Fibrilación Atrial/economía , Humanos , Masculino , Femenino , Ablación por Catéter/métodos , Ablación por Catéter/economía , Persona de Mediana Edad , Resultado del Tratamiento , Análisis Costo-Beneficio , Estudios Retrospectivos , Anciano , Criocirugía/métodos , Criocirugía/economía , Estudios de SeguimientoRESUMEN
BACKGROUND: Long-term clinical outcomes of catheter ablation (CA) compared to thoracoscopic surgical ablation (SA) to treat patients with long-standing persistent atrial fibrillation (LSPAF) are not known. OBJECTIVE: The purpose of this study was to compare the long-term (36-month) clinical efficacy, quality of life, and cost-effectiveness of SA and CA in LSPAF. METHODS: Participants were followed up for 3 years using implantable loop recorders and questionnaires to assess the change in quality of life. Intention-to-treat analyses were used to report the findings. RESULTS: Of the 115 patients with LSPAF treated, 104 (90.4%) completed 36-month follow-up [CA: n = 57 (95%); SA: n = 47 (85%)]. After a single procedure without antiarrhythmic drugs, 7 patients (12%) in the CA arm and 5 (11%) in the SA arm [hazard ratio 1.22; 95% confidence interval (CI) 0.81-1.83; P = .41] were free from atrial fibrillation/tachycardia (AF/AT) ≥30 seconds at 36 months. Thirty-three patients (58%) in the CA arm and 26 (55%) in the SA arm (hazard ratio 1.04; 95% CI 0.57-1.88; P = .91) had their AF/AT burden reduced by ≥75%. The overall impact on health-related quality of life was similar, with mean quality-adjusted life year estimates of 2.45 (95% CI 2.31-2.59) for CA and 2.32 (95% CI 2.13-2.52) for SA. Estimated costs were higher for SA (mean £24,682; 95% CI £21,746-£27,618) than for CA (mean £18,002; 95% CI £15,422-£20,581). CONCLUSION: In symptomatic LSPAF, CA and SA were equally effective at achieving arrhythmia outcomes (freedom from AF/AT ≥30 seconds and ≥75% burden reduction) after a single procedure without antiarrhythmic drugs. However, SA is significantly more costly than CA.
Asunto(s)
Fibrilación Atrial , Ablación por Catéter , Análisis Costo-Beneficio , Calidad de Vida , Toracoscopía , Humanos , Fibrilación Atrial/cirugía , Fibrilación Atrial/fisiopatología , Fibrilación Atrial/economía , Masculino , Femenino , Ablación por Catéter/métodos , Ablación por Catéter/economía , Persona de Mediana Edad , Resultado del Tratamiento , Toracoscopía/métodos , Toracoscopía/economía , Estudios de Seguimiento , Electrocardiografía Ambulatoria/métodos , Electrocardiografía Ambulatoria/economía , Anciano , Factores de TiempoRESUMEN
OBJECTIVES: Pulsed field ablation (PFA) is a promising new ablation modality for the treatment of atrial fibrillation (AF) that has recently become available in the UK National Health Service (NHS). We provide the first known economic evaluation of the technology. METHODS: A cost-comparison model was developed to compare the expected 12-month costs of treating AF using the pentaspline PFA catheter compared with cryoablation for a single hypothetical patient. Model parameters were based on a recent cost-effectiveness analysis by the National Institute for Health and Care Excellence where possible or published literature otherwise. Deterministic sensitivity, scenario and threshold analyses were conducted. RESULTS: Costs for a single patient treated with PFA were -3% (-£343) less over 12 months than those who received treatment with cryoablation. PFA was associated with 16% higher catheter costs but repeat ablation costs were over 50% less, driven by a reduction in repeat ablations required. Costs of managing complications were -£211 less in total for PFA compared with cryoablation. CONCLUSIONS: Routine adoption of PFA with the pentaspline PFA catheter looks to be as affordable for the NHS as current treatment alternative cryoablation.
Asunto(s)
Fibrilación Atrial , Ablación por Catéter , Análisis Costo-Beneficio , Criocirugía , Medicina Estatal , Fibrilación Atrial/cirugía , Fibrilación Atrial/economía , Fibrilación Atrial/terapia , Humanos , Criocirugía/economía , Criocirugía/métodos , Reino Unido , Ablación por Catéter/economía , Ablación por Catéter/métodos , Medicina Estatal/economíaRESUMEN
BACKGROUND: During the COVID-19 pandemic, professional societies recommended deferral of elective procedures for optimal resource utilization. OBJECTIVE: We sought to assess changes in procedural trends and outcomes of electrophysiology (EP) procedures during the pandemic. METHODS: National Inpatient Sample databases were used to identify all EP procedures performed in the United States (2016-2020) by International Classification of Diseases, Tenth Revision codes. We evaluated trends in utilization, cost/revenue, and outcomes from EP procedures performed. RESULTS: An estimated 1.35 million EP procedures (82% devices and 18% catheter ablations) were performed (2016-2020) with significant yearly uptrend. During the pandemic, there was a substantial decline in EP procedure utilization from a 5-year peak of 298 cases/million population in the second quarter of 2019 to a nadir of 220 cases in the second quarter of 2020. In 2020, the pandemic was associated with the loss of 50,233 projected EP procedures (39,337 devices and 10,896 ablations) with subsequent revenue loss of $7.06 billion. This deficit was driven by revenue deficit from dual-chamber permanent pacemaker (PPM) utilization ($2.88 billion, 49.3% of lost cases), ablation procedures ($1.84 billion, 21.7% of lost cases), and implantable cardioverter-defibrillator implantation ($1.36 billion, 12.0% of lost cases). To the contrary, there was a 9.4% increase in the utilization of leadless PPM. EP device implantation during the pandemic was associated with higher adverse in-hospital events (9.4% vs 8.0%; P < .001). CONCLUSION: In the United States, the significant decline in EP procedures during the pandemic was primarily driven by the reduction in dual-chamber PPM utilization, followed by arrhythmia ablation and implantable cardioverter-defibrillator implantation. There was a substantial increase in leadless PPM utilization during the pandemic.
Asunto(s)
COVID-19 , Técnicas Electrofisiológicas Cardíacas , Humanos , COVID-19/epidemiología , Estados Unidos/epidemiología , Masculino , Femenino , Técnicas Electrofisiológicas Cardíacas/economía , Técnicas Electrofisiológicas Cardíacas/métodos , SARS-CoV-2 , Anciano , Arritmias Cardíacas/terapia , Arritmias Cardíacas/epidemiología , Arritmias Cardíacas/economía , Ablación por Catéter/economía , Ablación por Catéter/métodos , Ablación por Catéter/estadística & datos numéricos , Pandemias , Persona de Mediana EdadRESUMEN
OBJECTIVE: Superficial venous incompetence (SVI) is a common disease that causes significant quality of life (QoL) impairment. There is a need for more health economic evaluations of SVI treatment. The aim of this study was to perform a cost effectiveness analysis in patients with great saphenous vein (GSV) incompetence comparing radiofrequency ablation (RFA), high ligation and stripping (HL/S), and no treatment or conservative treatment with one year follow up. METHODS: Randomised controlled trial economic analysis from an ongoing trial; 143 patients (156 limbs) with GSV incompetence (CEAP clinical class 2 - 6) were included. Treatment was performed with RFA or HL/S. Follow up was performed up to one year using duplex ultrasound, revised venous clinical severity score (r-VCSS), Aberdeen Varicose Vein Questionnaire (AVVQ), and EuroQol-5D-3L (EQ-5D-3L). RESULTS: Seventy-eight limbs were treated with RFA and HL/S respectively. No treatment or conservative treatment was assumed to have zero in treatment cost and no treatment benefit. In the RFA group, one limb had reflux in the GSV after one month and three limbs after one year. In HL/S, two limbs had remaining reflux in the treated area at one month and one year. Both disease severity (r-VCSS, p = .004) and QoL (AVVQ, p = .021 and EQ-5D-3L, p = .028) were significantly improved over time. The QALY gain was 0.21 for RFA and 0.17 for HL/S. The cost per patient was calculated as 1 292 for RFA and 2 303 for HL/S. The cost per QALY (compared with no treatment or conservative treatment) was 6 155 for RFA and 13 549 for HL/S. With added cost for days absent from work the cost per QALY was 7 358 for RFA and 24 197 for HL/S. The cost per QALY for both methods was well below the threshold suggested by Swedish National Board of Health. CONCLUSION: RFA is more cost effective than HL/S and no treatment or conservative treatment at one year follow up.
Asunto(s)
Análisis Costo-Beneficio , Calidad de Vida , Ablación por Radiofrecuencia , Vena Safena , Insuficiencia Venosa , Humanos , Ligadura/economía , Vena Safena/cirugía , Vena Safena/diagnóstico por imagen , Insuficiencia Venosa/cirugía , Insuficiencia Venosa/economía , Insuficiencia Venosa/diagnóstico por imagen , Femenino , Masculino , Persona de Mediana Edad , Resultado del Tratamiento , Ablación por Radiofrecuencia/economía , Ablación por Radiofrecuencia/efectos adversos , Años de Vida Ajustados por Calidad de Vida , Factores de Tiempo , Procedimientos Quirúrgicos Vasculares/economía , Procedimientos Quirúrgicos Vasculares/efectos adversos , Procedimientos Quirúrgicos Vasculares/métodos , Anciano , Ablación por Catéter/economía , Ablación por Catéter/efectos adversos , Ablación por Catéter/métodos , Adulto , Costos de la Atención en Salud , Várices/cirugía , Várices/economía , Várices/diagnóstico por imagen , Análisis de Costo-EfectividadRESUMEN
Background Recent trials comparing catheter ablation to medical therapy in patients with heart failure (HF) with symptomatic atrial fibrillation despite first-line management have demonstrated a reduction in adverse outcomes. We performed an economic evaluation to estimate the cost-utility of catheter ablation as second line therapy in patients with HF with reduced ejection fraction. Methods and Results A Markov model with health states of alive, dead, and alive with amiodarone toxicity was constructed, using the perspective of the Canadian healthcare payer. Patients in the alive states were at risk of HF and non-HF hospitalizations. Parameters were obtained from randomized trials and Alberta health system data for costs and outcomes. A lifetime time horizon was adopted, with discounting at 3.0% annually. Probabilistic and 1-way sensitivity analyses were performed. Costs are reported in 2018 Canadian dollars. A patient treated with catheter ablation experienced lifetime costs of $64 960 and 5.63 quality-adjusted life-years (QALY), compared with $49 865 and 5.18 QALYs for medical treatment. The incremental cost-effectiveness ratio was $35 360/QALY (95% CI, $21 518-77 419), with a 90% chance of being cost-effective at a willingness-to-pay threshold of $50 000/QALY. A minimum mortality reduction of 28%, or a minimum duration of benefit of >1 to 2 years was required for catheter ablation to be attractive at this threshold. Conclusions Catheter ablation is likely to be cost-effective as a second line intervention for patients with HF with symptomatic atrial fibrillation, with incremental cost-effectiveness ratio $35 360/QALY, as long as over half of the relative mortality benefit observed in extant trials is borne out in future studies.
Asunto(s)
Antiarrítmicos/economía , Antiarrítmicos/uso terapéutico , Fibrilación Atrial/terapia , Ablación por Catéter/economía , Costos de la Atención en Salud , Insuficiencia Cardíaca/fisiopatología , Adulto , Anciano , Anciano de 80 o más Años , Alberta , Antiarrítmicos/efectos adversos , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/economía , Fibrilación Atrial/fisiopatología , Ablación por Catéter/efectos adversos , Análisis Costo-Beneficio , Costos de los Medicamentos , Femenino , Insuficiencia Cardíaca/diagnóstico , Humanos , Masculino , Cadenas de Markov , Persona de Mediana Edad , Años de Vida Ajustados por Calidad de Vida , Ensayos Clínicos Controlados Aleatorios como AsuntoRESUMEN
BACKGROUND: Since the early descriptions of large series of accessory atrioventricular pathway ablations in adults and adolescents over 20 years ago, there have been limited published reports based on more recent experiences of large referral centers. We aimed to characterize accessory pathway distribution and features in a large community-based population that influence ablation outcomes using a tiered approach to ablation. METHODS: Retrospective analysis of 289 patients (age 14-81) who underwent accessory ablation from 2015-2019 was performed. Pathways were categorized into anteroseptal, left freewall, posteroseptal, and right freewall locations. We analyzed patient and pathway features to identify factors associated with prolonged procedure time parameters. RESULTS: Initial ablation success rate was 94.7% with long-term success rate of 93.4% and median follow-up of 931 days. Accessory pathways were in left freewall (61.6%), posteroseptal (24.6%), right freewall (9.6%), and anteroseptal (4.3%) locations. Procedure outcome was dependent on pathway location. Acute success was highest for left freewall pathways (97.1%) with lowest case times (144 ± 68 min) and fluoroscopy times (15 ± 19 min). Longest procedure time parameters were seen with anteroseptal, left anterolateral, epicardial-coronary sinus, and right anterolateral pathway ablations. CONCLUSIONS: In this community-based adult and adolescent population, majority of the accessory pathways are in the left freewall and posteroseptal region and tend to be more easily ablated. A tiered approach with initial use of standard ablation equipment before the deployment of more advance tools, such as irrigated tips and 3D mapping, is cost effective without sacrificing overall efficacy.
Asunto(s)
Fascículo Atrioventricular Accesorio/cirugía , Arritmias Cardíacas/cirugía , Ablación por Catéter/tendencias , Servicios de Salud Comunitaria/tendencias , Prestación Integrada de Atención de Salud/tendencias , Pautas de la Práctica en Medicina/tendencias , Irrigación Terapéutica/tendencias , Fascículo Atrioventricular Accesorio/diagnóstico , Fascículo Atrioventricular Accesorio/economía , Fascículo Atrioventricular Accesorio/fisiopatología , Potenciales de Acción , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Arritmias Cardíacas/diagnóstico , Arritmias Cardíacas/economía , Arritmias Cardíacas/fisiopatología , Ablación por Catéter/efectos adversos , Ablación por Catéter/economía , Toma de Decisiones Clínicas , Servicios de Salud Comunitaria/economía , Análisis Costo-Beneficio , Prestación Integrada de Atención de Salud/economía , Femenino , Costos de la Atención en Salud/tendencias , Frecuencia Cardíaca , Humanos , Masculino , Persona de Mediana Edad , Tempo Operativo , Pautas de la Práctica en Medicina/economía , Estudios Retrospectivos , Irrigación Terapéutica/efectos adversos , Irrigación Terapéutica/economía , Factores de Tiempo , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND: Combined catheter ablation (CA) and left atrial appendage closure (LAAC) have been proposed for management of symptomatic atrial fibrillation (AF) in patients with high stroke and bleeding risk. We assessed the cost-effectiveness of combined CA and LAAC compared with CA and standard oral anticoagulation (OAC) in symptomatic AF. METHODS: A Markov model was developed to assess total costs, quality-adjusted life-years (QALYs), and the incremental cost-effectiveness ratio among 2 post-CA strategies: (1) standard OAC and (2) LAAC (combined CA and LAAC procedure). The base-case used a 10-year time horizon and consisted of a hypothetical cohort of patients aged 65â¯years with symptomatic AF, with high thrombotic (CHA2DS2-VAScâ¯=â¯3) and bleeding risk (HAS-BLEDâ¯=â¯3), and planned for AF ablation. Values for transition probabilities, utilities, and costs were derived from the literature. Costs were converted to 2020 US dollars. Half-cycle correction was applied, and costs and QALYs were discounted at 3% annually. Sensitivity analyses were performed for significant variables and scenario analyses for higher embolic risk. RESULTS: In the base-case cohort of 10,000 patients followed for 10â¯years, total costs for the LAAC strategy were $29,027 and for OAC strategy were $27,896. The LAAC strategy was associated with 122 fewer disabling strokes and 203 fewer intracranial hemorrhages per 10,000 patients compared with the OAC strategy. The LAAC strategy had an incremental cost-effectiveness ratio of $11,072/QALY. In sensitivity analyses, although cost-effectiveness was highly dependent on the risk of intracranial hemorrhage in the LAAC strategy and the cost of the combined procedure, LAAC was superior to OAC under the most circumstances. Scenario analyses demonstrated that the combined procedure was more cost-effective in patients with higher stroke risk. CONCLUSIONS: In symptomatic AF patients with high stroke and bleeding risk who are planned for CA, the combined CA and LAAC procedure may be a cost-effective therapeutic option and be more beneficial to patients with CHA2DS2-VASc risk scoreâ¯≥3.
Asunto(s)
Anticoagulantes/uso terapéutico , Apéndice Atrial/cirugía , Fibrilación Atrial/cirugía , Ablación por Catéter/economía , Anciano , Fibrilación Atrial/complicaciones , Terapia Combinada/economía , Terapia Combinada/métodos , Análisis Costo-Beneficio , Hemorragia/etiología , Humanos , Cadenas de Markov , Años de Vida Ajustados por Calidad de Vida , Accidente Cerebrovascular/etiologíaRESUMEN
BACKGROUND: Catheter ablation for complex left-atrial arrhythmia is increasing worldwide with many centres admitting patients overnight. Same-day procedures using conscious sedation carry significant benefits to patients/healthcare providers but data are limited. We evaluated the safety and cost-effectiveness of same-day complex left-atrial arrhythmia ablation. METHOD: Multi-centre retrospective cohort study of all consecutive complex elective left-atrial ablation procedures performed between January 2011 and December 2019. Data were collected on planned same-day discharge versus overnight stay, baseline parameters, procedure details/success, ablation technology, post-operative complications, unplanned overnight admissions/outcomes at 4-months and mortality up to April 2020. A cost analysis of potential savings was also performed. RESULTS: A total of 967 consecutive patients underwent complex left-ablation using radiofrequency (point-by-point ablation aided by 3D-mapping or PVAC catheter ablation with fluoroscopic screening) or cryoballoon-ablation (mean age: 60.9 ± 11.6 years, range 23-83 yrs., 572 [59%] females). The majority of patients had isolation of pulmonary veins alone (n = 846, 87%) and most using conscious-sedation alone (n = 921, 95%). Of the total cohort, 414 (43%) had planned same-day procedure with 35 (8%) admitted overnight due to major (n = 5) or minor (n = 30) complications. Overall acute procedural success-rate was 96% (n = 932). Complications in planned overnight-stay/same-day cohorts were low. At 4-month follow-up there were 62 (6.4%) readmissions (femoral haematomas, palpitation, other reasons); there were 3 deaths at mean follow-up of 42.0 ± 27.6 months, none related to the procedure. Overnight stay costs £350; the same-day ablation policy over this period would have saved £310,450. CONCLUSIONS: Same-day complex left-atrial catheter ablation using conscious sedation is safe and cost-effective with significant benefits for patients and healthcare providers. This is especially important in the current financial climate and Covid-19 pandemic.
Asunto(s)
Procedimientos Quirúrgicos Ambulatorios/economía , Arritmias Cardíacas/cirugía , Ablación por Catéter/economía , Análisis Costo-Beneficio , Adulto , Anciano , Anciano de 80 o más Años , Procedimientos Quirúrgicos Ambulatorios/efectos adversos , Ablación por Catéter/efectos adversos , Estudios de Cohortes , Femenino , Atrios Cardíacos/cirugía , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Adulto JovenRESUMEN
BACKGROUND: Randomized clinical trials have demonstrated that catheter ablation for atrial fibrillation in patients with heart failure with reduced ejection fraction may improve survival and other cardiovascular outcomes. METHODS: We constructed a decision-analytic Markov model to estimate the costs and benefits of catheter ablation and medical management in patients with symptomatic heart failure with reduced ejection fraction (left ventricular ejection fraction ≤35%) and atrial fibrillation over a lifetime horizon. Evidence from the published literature informed the model inputs, including clinical effectiveness data from meta-analyses. Probabilistic and deterministic sensitivity analyses were performed. A 3% discount rate was applied to both future costs and benefits. The primary outcome was the incremental cost-effectiveness ratio assessed from the US health care sector perspective. RESULTS: Catheter ablation was associated with 6.47 (95% CI, 5.89-6.93) quality-adjusted life years (QALYs) and a total cost of $105 657 (95% CI, $55 311-$191 934; 2018 US dollars), compared with 5.30 (95% CI, 5.20-5.39) QALYs and $63 040 (95% CI, $37 624-$102 260) for medical management. The incremental cost-effectiveness ratio for catheter ablation compared with medical management was $38 496 (95% CI, $5583-$117 510) per QALY gained. Model inputs with the greatest variation on incremental cost-effectiveness ratio estimates were the cost of ablation and the effect of catheter ablation on mortality reduction. When assuming a more conservative estimate of the treatment effect of catheter ablation on mortality (hazard ratio of 0.86), the estimated incremental cost-effectiveness ratio was $74 403 per QALY gained. At a willingness-to-pay threshold of $100 000 per QALY gained, atrial fibrillation ablation was found to be economically favorable compared with medical management in 95% of simulations. CONCLUSIONS: Catheter ablation in patients with heart failure with reduced ejection fraction patients and atrial fibrillation may be considered economically attractive at current benchmarks for societal willingness-to-pay in the United States.
Asunto(s)
Antiarrítmicos/economía , Antiarrítmicos/uso terapéutico , Fibrilación Atrial/terapia , Ablación por Catéter/economía , Costos de la Atención en Salud , Insuficiencia Cardíaca/fisiopatología , Volumen Sistólico , Función Ventricular Izquierda , Antiarrítmicos/efectos adversos , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/economía , Fibrilación Atrial/fisiopatología , Ablación por Catéter/efectos adversos , Análisis Costo-Beneficio , Técnicas de Apoyo para la Decisión , Costos de los Medicamentos , Insuficiencia Cardíaca/diagnóstico , Humanos , Cadenas de Markov , Calidad de Vida , Años de Vida Ajustados por Calidad de Vida , Factores de Tiempo , Resultado del TratamientoRESUMEN
Recurrence of paroxysmal supraventricular tachycardia (PSVT) has been reported to be lower in patients treated with radiofrequency catheter ablation (RFCA) than in those who are not. Few population-based surveys have stated the cost-effectiveness related to this treatment. We, therefore, performed a nationwide retrospective study using National Health Insurance Research Database (NHIRD) data from 2001-2012 in Taiwan. The incidence of PSVT-related admissions was computed from patients' first admission for a primary PSVT diagnosis. There were 21,086 patients hospitalized due to first-time PSVT, of whom 13,075 underwent RFCA, with 374 recurrences (2.86%). In contrast, 1751 (21.86%) of the remaining 8011 patients who did not receive RFCA, most of whom had financial concerns, experienced PSVT recurrence. The relative PSVT recurrence risk in those who did not receive RFCA was 7.6 times (95%CI: 6.67-8.33) that of those who did undergo RFCA. In conclusion, the PSVT recurrence rate was much higher in patients who did not receive RFCA at their first admission. Furthermore, RFCA proved cost-effective, with the ratio of the incremental cost-effectiveness ratio (ICER) and gross domestic product (GDP) being only 1.15. To prevent readmission and avoid incremental cost, the authority could provide a financial supplement for every patient so that the procedure is performed, reducing the PSVT-recurrence life-years (disease-specific DALY).
Asunto(s)
Macrodatos , Ablación por Catéter/economía , Análisis Costo-Beneficio , Readmisión del Paciente/economía , Taquicardia Supraventricular/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Encuestas y Cuestionarios , TaiwánRESUMEN
BACKGROUND: Utilization of catheter ablation of ventricular tachycardia (VT) has steadily increased in recent years. Exploring short-term outcomes is vital in health care planning and resource allocation. METHODS: The Nationwide Readmissions Database from 2010 to 2014 was queried using the ICD-9 codes for VT (427.1) and catheter ablation (37.34) to identify study population. Incidence, causes of 30-day readmission, in-hospital complications as well as predictors of 30-day readmissions, complications, and cost of care were analyzed. RESULTS: Among 11 725 patients who survived to discharge after index admission for VT ablation, 1911 (16.3%) were readmitted within 30 days. Paroxysmal VT was the most common cause of 30-day readmission (39.51%). Dyslipidemia, chronic kidney disease (CKD), previous CABG, congestive heart failure (CHF), chronic pulmonary disease, and anemia predicted increased risk of 30-day readmissions. The overall in-hospital complication rate was 8.2% with vascular and cardiac complications being the most common. Co-existing CKD and CHF and the need for mechanical circulatory support (MCS) predicted higher complication rates. Similarly increasing age, CKD, CHF, anemia, in-hospital use of MCS or left heart catheterization, teaching hospital, and disposition to nursing facilities predicted higher cost. CONCLUSION: Approximately one in six patients was readmitted after VT ablation, with paroxysmal VT being the most common cause of the readmission. A complication rate of 8.2% was noted. We also identified a predictive model for increased risk of readmission, complication, and factors influencing the cost of care that can be utilized to improve the outcomes related to VT ablation.
Asunto(s)
Ablación por Catéter/métodos , Readmisión del Paciente/estadística & datos numéricos , Complicaciones Posoperatorias/epidemiología , Taquicardia Ventricular/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Ablación por Catéter/economía , Bases de Datos Factuales , Femenino , Humanos , Pacientes Internos , Masculino , Persona de Mediana EdadRESUMEN
Objective: Catheter ablation is an important treatment for ventricular tachycardia (VT) that reduces the frequency of episodes of VT. We sought to evaluate the cost-effectiveness of catheter ablation versus antiarrhythmic drug (AAD) therapy. Methods: A decision-analytic Markov model was used to calculate the costs and health outcomes of catheter ablation or AAD treatment of VT for a hypothetical cohort of patients with ischaemic cardiomyopathy and an implantable cardioverter-defibrillator. The health states and input parameters of the model were informed by patient-reported health-related quality of life (HRQL) data using randomised clinical trial (RCT)-level evidence wherever possible. Costs were calculated from a 2018 UK perspective. Results: Catheter ablation versus AAD therapy had an incremental cost-effectiveness ratio (ICER) of £144 150 (161 448) per quality-adjusted life-year gained, over a 5-year time horizon. This ICER was driven by small differences in patient-reported HRQL between AAD therapy and catheter ablation. However, only three of six RCTs had measured patient-reported HRQL, and when this was done, it was assessed infrequently. Using probabilistic sensitivity analyses, the likelihood of catheter ablation being cost-effective was only 11%, assuming a willingness-to-pay threshold of £30 000 used by the UK's National Institute for Health and Care Excellence. Conclusion: Catheter ablation of VT is unlikely to be cost-effective compared with AAD therapy based on the current randomised trial evidence. However, better designed studies incorporating detailed and more frequent quality of life assessments are needed to provide more robust and informed cost-effectiveness analyses.
Asunto(s)
Antiarrítmicos/economía , Antiarrítmicos/uso terapéutico , Cardiomiopatías/complicaciones , Ablación por Catéter/economía , Costos de la Atención en Salud , Isquemia Miocárdica/complicaciones , Taquicardia Ventricular/economía , Taquicardia Ventricular/terapia , Anciano , Antiarrítmicos/efectos adversos , Cardiomiopatías/diagnóstico , Cardiomiopatías/economía , Cardiomiopatías/terapia , Ablación por Catéter/efectos adversos , Análisis Costo-Beneficio , Desfibriladores Implantables/economía , Costos de los Medicamentos , Cardioversión Eléctrica/economía , Cardioversión Eléctrica/instrumentación , Medicina Basada en la Evidencia/economía , Femenino , Humanos , Masculino , Cadenas de Markov , Persona de Mediana Edad , Modelos Económicos , Isquemia Miocárdica/diagnóstico , Isquemia Miocárdica/economía , Isquemia Miocárdica/terapia , Calidad de Vida , Ensayos Clínicos Controlados Aleatorios como Asunto/economía , Taquicardia Ventricular/diagnóstico , Taquicardia Ventricular/etiología , Resultado del TratamientoRESUMEN
Information on paroxysmal supraventricular tachycardia (PSVT) patient characteristics and the associated economic burden of the disease is limited. Therefore, we sought to characterize newly diagnosed PSVT patients and quantify their healthcare resource use and expenditures. We used enrollment, demographic, and claims data from IBM MarketScan Research Database and Medicare Limited Data Set (LDS) to identify patients newly diagnosed with PSVT (ICD-9: 427.0; ICD-10: I47.1) from 10/1/2012 to 9/30/2016. Patients were required to be observable 1-year before and after index diagnosis. Patients were stratified by age (<65 years and ≥65 years), and propensity-matched to patients without PSVT. Expenditures and healthcare resource use were analyzed 1 year before and 1-year following index diagnosis. Among 49,316 patients <65 years and 23,954 patients ≥65 years, most were female (64% and 63%, respectively). Compared with matched controls, all PSVT patients had significantly more emergency department visits pre- and postdiagnosis, and more hospitalizations following diagnosis. Mean annual per patient expenditures paid by insurers were significantly higher in the year post-PSVT diagnosis, tripling for patients <65 years ($9,028 to $29,867) and nearly doubling for patients ≥65 years ($10,867 to $20,143). Spending for PSVT services accounted for 43% and 33% of the increase in expenditures in these patient-groups, respectively. Few patients had an ablation within 1 year of diagnosis, although ablations were more frequent in patients age <65 years (13% vs 3%). In conclusion, PSVT imposes a substantial economic burden, with increases in expenditures following initial diagnosis in both younger (<65 years) and older (≥65 years) patients who are not accounted for by cardiac ablation spending alone.
Asunto(s)
Ablación por Catéter/economía , Gastos en Salud/estadística & datos numéricos , Taquicardia Paroxística/diagnóstico , Taquicardia Supraventricular/diagnóstico , Anciano , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Riesgo , Taquicardia Paroxística/economía , Taquicardia Paroxística/cirugía , Taquicardia Supraventricular/economía , Taquicardia Supraventricular/cirugía , Factores de TiempoRESUMEN
Central airway obstruction (CAO) is associated with significant morbidity and increased mortality. Bronchoscopic electrosurgical and laser ablative tools have proven to be safe and effective instruments for the treatment of malignant CAO. Although therapeutic modalities such as electrocautery, argon plasma coagulation, and laser have been used for decades, additional tools including radiofrequency ablation catheters continue to be developed for the treatment of CAO. These modalities are considered safe in the hands of experienced operators, although serious complications can occur. This review describes various electrosurgical and laser therapy tools used for the treatment of malignant CAO along with the specific advantages and disadvantages of each device.
Asunto(s)
Obstrucción de las Vías Aéreas/cirugía , Coagulación con Plasma de Argón/métodos , Broncoscopía , Ablación por Catéter/métodos , Electrocirugia/métodos , Terapia por Láser/métodos , Neoplasias del Sistema Respiratorio/cirugía , Obstrucción de las Vías Aéreas/etiología , Coagulación con Plasma de Argón/efectos adversos , Coagulación con Plasma de Argón/economía , Bronquios , Ablación por Catéter/efectos adversos , Ablación por Catéter/economía , Electrocoagulación/efectos adversos , Electrocoagulación/economía , Electrocoagulación/métodos , Electrocirugia/efectos adversos , Electrocirugia/economía , Humanos , Terapia por Láser/efectos adversos , Terapia por Láser/economía , Neoplasias/complicaciones , Neoplasias/cirugía , Neoplasias del Sistema Respiratorio/complicaciones , TráqueaRESUMEN
BACKGROUND: Data on the longitudinal impact of surgical ablation (SA) for atrial fibrillation (AF) in patients undergoing coronary artery bypass grafting (CABG) remain limited. This study examined 2-year risk-adjusted mortality and total hospital costs in Medicare beneficiaries with AF requiring CABG with or without SA. METHODS: CABG was performed in 3745 Medicare beneficiaries with AF in 2013, with concomitant SA in 17% (626 of 3745). Risk-adjusted mortality, morbidity, and cost during the first 2 postoperative years for patients with SA and those without SA were compared. A piecewise Cox proportional hazard model (0-90 days and 91-729 days) was used to risk-adjust mortality. RESULTS: Compared with the no SA group, the SA group had lower rates of heart failure before surgery (31% vs 36%), chronic lung disease (27% vs 33%), renal failure (4% vs 7%), and urgent or emergent presentation (34% vs 49%) (all P < .05). Risk-adjusted index admission costs were higher with SA (rate ratio [RR], 1.11; P < .01), as were readmissions for AF (hazard ratio [HR], 1.14; 95% confidence interval [CI], 1.00-1.29; P = .04) and pacemaker/defibrillator implantation (HR, 1.37; 95%, 1.08-1.74; P = .01). Risk-adjusted inpatient days and inpatient costs were similar after 2 years (RR, 0.97; P = .31 and RR = 1.04; P = .17, respectively); however, the risk-adjusted hazard for late mortality (91-729 days) was significantly lower with SA (HR, 0.71; 95% CI, 0.52-0.97; P = .03). CONCLUSIONS: In patients with AF requiring CABG, SA was associated with a 29% lower risk-adjusted hazard for late mortality. Index hospital costs were higher with SA, but total inpatient costs were not different in the 2 groups after 2 years. SA appears to be a cost-effective intervention to enhance late 2-year survival in patients with AF undergoing CABG.
Asunto(s)
Fibrilación Atrial , Ablación por Catéter , Puente de Arteria Coronaria , Anciano , Fibrilación Atrial/epidemiología , Fibrilación Atrial/mortalidad , Fibrilación Atrial/cirugía , Ablación por Catéter/economía , Ablación por Catéter/mortalidad , Estudios de Cohortes , Comorbilidad , Puente de Arteria Coronaria/economía , Puente de Arteria Coronaria/mortalidad , Análisis Costo-Beneficio , Femenino , Humanos , Masculino , Medicare , Persona de Mediana Edad , Complicaciones Posoperatorias/economía , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/mortalidad , Estados UnidosRESUMEN
OBJECTIVES: Assessing the cost-effectiveness credentials of this intervention in patients with concomitant atrial fibrillation (AF) and heart failure (HF) compared with usual medical therapy. DESIGN: A Markov model comprising two health states (ie, alive or dead) was constructed. The transition probabilities were directly derived from published Kaplan-Meier curves of the pivotal randomised controlled trial and extrapolated over the cohort's lifetime using recommended methods. Costs of catheter ablation, outpatient consultations, hospitalisation, medications and examinations were included. Resource use and unit costs were sourced from government websites or published literature. A lifetime horizon and a healthcare system perspective were taken. All costs and benefits were discounted at 3% annually. Deterministic (DSA) and probabilistic sensitivity analyses (PSA) were run around the key model parameters to test the robustness of the base case results. PARTICIPANTS: A hypothetical Australian cohort of patients with concomitant AF and HF who are resistant to antiarrhythmic treatment. INTERVENTIONS: Catheter ablation versus medical therapy. RESULTS: The catheter ablation was associated with a cost of $A44 377 per person, in comparison to $A28 506 for the medical therapy alone over a lifetime. Catheter ablation contributed to 4.58 quality-adjusted life years (QALYs) and 6.99 LY gains compared with 4.30 QALYs and 6.53 LY gains, respectively, in the medical therapy arm. The incremental cost-effectiveness ratio was $A55 942/QALY or $A35 020/LY. The DSA showed that results were highly sensitive to costs of ablation and time horizon. The PSA yielded very consistent results with the base case. CONCLUSIONS: Offering catheter ablation procedure to patients with systematic paroxysmal or persistent AF who failed to respond to antiarrhythmic drugs was associated with higher costs, greater benefits. When compared with medical therapy alone, this intervention is not cost-effective from an Australia healthcare system perspective.
Asunto(s)
Fibrilación Atrial/terapia , Ablación por Catéter/economía , Análisis Costo-Beneficio , Insuficiencia Cardíaca/terapia , Antiarrítmicos/uso terapéutico , Fibrilación Atrial/complicaciones , Australia , Femenino , Insuficiencia Cardíaca/complicaciones , Humanos , Masculino , Cadenas de Markov , Persona de Mediana Edad , Años de Vida Ajustados por Calidad de Vida , Seguridad , Evaluación de la Tecnología Biomédica/economía , Resultado del TratamientoRESUMEN
AIMS: The TactiCath Contact Force Ablation Catheter Study for Atrial Fibrillation (TOCCASTAR) clinical trial compared clinical outcomes using a contact force (CF) sensing ablation catheter (TactiCath) with a catheter that lacked CF measurement. This analysis links recorded events in the TOCCASTAR study and a large claims database, IBM MarketScan®, to determine the economic impact of using CF sensing during atrial fibrillation (AF) ablation. METHODS AND RESULTS: Clinical events including repeat ablation, use of antiarrhythmic drugs, hospitalization, perforation, pericarditis, pneumothorax, pulmonary edema, pulmonary vein stenosis, tamponade, and vascular access complications were adjudicated in the year after ablation. CF was characterized as optimal if greater than or equal to 90% lesion was performed with greater than or equal to 10 g of CF. A probabilistic 1:1 linkage was created for subjects in MarketScan® with the same events in the year after ablation, and the cost was evaluated over 10 000 iterations. Of the 279 subjects in TOCCASTAR, 145 were ablated using CF (57% with optimal CF), and 134 were ablated without CF. In the MarketScan® cohort, 9811 subjects who underwent AF ablation were used to determine events and costs. For subjects ablated with optimal CF, total cost was $19 271 ± 3705 in the year after ablation. For ablation lacking CF measurement, cost was $22 673 ± 3079 (difference of $3402, P < .001). In 73% of simulations, optimal CF was associated with lower cost in the year after ablation. CONCLUSION: Compared to ablation without CF, there was a decrease in healthcare cost of $3402 per subject in the first year after the procedure when optimal CF was used.