Feasibility and cost-effectiveness of stroke prevention through community screening for atrial fibrillation using iPhone ECG in pharmacies. The SEARCH-AF study
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Published on: December 11, 2019
Nicole Lowres, Lis Neubeck, Glenn Salkeld
1S. Ben Freedman, Cardiology Department, Level 3, Concord Repatriation General Hospital, Hospital Road, Concord NSW 2137, Australia, Tel.: +612 9767 7358, Fax: +612 9767 6780,
Insights
Community screening for atrial fibrillation (AF) using iPhone electrocardiograms (iECGs) in pharmacies is feasible and cost-effective. Early detection of unknown AF can significantly reduce stroke risk and improve patient outcomes.
Area of Science:
- Cardiology
- Public Health
- Health Economics
Background:
- Atrial fibrillation (AF) is a major cause of stroke, often undetected before a stroke occurs.
- Community-based screening for unknown AF could reduce the stroke burden through early intervention.
- iPhone electrocardiogram (iECG) technology offers a potential tool for accessible AF screening.
Purpose of the Study:
- To investigate the feasibility and cost-effectiveness of community AF screening using iECGs in pharmacies.
- To determine the prevalence of previously undiagnosed AF in a community pharmacy setting.
- To evaluate the performance of an automated AF detection algorithm for iECG data.
Main Methods:
- Pharmacists conducted pulse palpation and iECG recordings on 1,000 customers aged ≥65 years.
- Cardiologists reviewed iECG recordings, with suspected new AF cases referred for general practitioner review and 12-lead ECG.
- An automated AF algorithm was retrospectively applied to iECG data; cost-effectiveness analysis was performed.
Main Results:
- Newly identified AF was detected in 1.5% of screened individuals, with a total AF prevalence of 6.7%.
- The automated iECG algorithm demonstrated high sensitivity (98.5%) and specificity (91.4%) for AF detection.
- The incremental cost-effectiveness ratio was favorable, particularly with improved anti-thrombotic treatment adherence.
Conclusions:
- Community-based AF screening using iECGs in pharmacies is a feasible and cost-effective strategy.
- The high rate of newly identified AF underscores the potential benefits of widespread community screening.
- Consideration should be given to recommending community iECG AF screening in clinical guidelines.
Abstract:
Atrial fibrillation (AF) causes a third of all strokes, but often goes undetected before stroke. Identification of unknown AF in the community and subsequent anti-thrombotic treatment could reduce stroke burden. We investigated community screening for unknown AF using an iPhone electrocardiogram (iECG) in pharmacies, and determined the cost-effectiveness of this strategy.Pharmacists performedpulse palpation and iECG recordings, with cardiologist iECG over-reading. General practitioner review/12-lead ECG was facilitated for suspected new AF. An automated AF algorithm was retrospectively applied to collected iECGs. Cost-effectiveness analysis incorporated costs of iECG screening, and treatment/outcome data from a United Kingdom cohort of 5,555 patients with incidentally detected asymptomatic AF. A total of 1,000 pharmacy customers aged ≥65 years (mean 76 ± 7 years; 44% male) were screened. Newly identified AF was found in 1.5% (95% CI, 0.8-2.5%); mean age 79 ± 6 years; all had CHA2DS2-VASc score ≥2. AF prevalence was 6.7% (67/1,000). The automated iECG algorithm showed 98.5% (CI, 92-100%) sensitivity for AF detection and 91.4% (CI, 89-93%) specificity. The incremental cost-effectiveness ratio of extending iECG screening into the community, based on 55% warfarin prescription adherence, would be $AUD5,988 (€3,142; $USD4,066) per Quality Adjusted Life Year gained and $AUD30,481 (€15,993; $USD20,695) for preventing one stroke. Sensitivity analysis indicated cost-effectiveness improved with increased treatment adherence.Screening with iECG in pharmacies with an automated algorithm is both feasible and cost-effective. The high and largely preventable stroke/thromboembolism risk of those with newly identified AF highlights the likely benefits of community AF screening. Guideline recommendation of community iECG AF screening should be considered.
