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Published on: February 26, 2013
Cost-utility analysis of routine oral anticoagulation for low-risk patients undergoing cardioversion for atrial
Shawn Chhabra1,2, Krishan Yadav3,4,5, Miguel Cortel-LeBlanc6,7
1Department of Emergency Medicine, University of Ottawa, 1053 Carling Avenue, Room EM 206 Box 227, Ottawa, ON, K1Y4E9, Canada. schhabra@toh.ca.
Insights
Routine oral anticoagulation (OAC) after cardioversion for acute atrial fibrillation/flutter (AF/AFL) is not cost-effective. Forgoing OAC offers slightly better quality-of-life and lower costs for patients without stroke risk factors.
Area of Science:
- Health Economics
- Cardiology
- Public Health Policy
Background:
- Canadian guidelines recommend four weeks of oral anticoagulation (OAC) for cardioversion of acute atrial fibrillation/flutter (AF/AFL), irrespective of stroke risk.
- Stroke following cardioversion, though infrequent, carries substantial morbidity and healthcare costs.
- Evaluating the cost-effectiveness of routine OAC post-cardioversion is crucial for optimizing patient care and resource allocation.
Purpose of the Study:
- To assess the cost-utility of providing routine four weeks of oral anticoagulation (OAC) versus no OAC after cardioversion for acute atrial fibrillation/flutter (AF/AFL).
- To compare clinical outcomes, quality-of-life, and costs from a Canadian public payer perspective.
- To inform clinical practice guidelines regarding anticoagulation strategies post-cardioversion.
Main Methods:
- A cost-utility analysis using a decision tree model was performed.
- The study compared no OAC versus four weeks of OAC in adults with acute AF/AFL and no risk factors (CCS Algorithm CHADS-65).
- Probabilistic sensitivity analysis with 10,000 Monte Carlo simulations evaluated the robustness of the findings.
Main Results:
- The no-OAC strategy was dominant, yielding slightly higher quality-adjusted life days (296 vs. 295) at a lower cost (CAN$108.86 vs. CAN$117.73).
- The incremental net monetary benefit favored the no-OAC strategy at $25.22.
- Probabilistic sensitivity analysis indicated the no-OAC option was cost-effective in 69.5% of iterations, driven by low post-cardioversion event rates.
Conclusions:
- Forgoing routine oral anticoagulation after cardioversion for acute AF/AFL in low-risk patients results in minimal differences in outcomes.
- The no-OAC strategy demonstrates a slight improvement in quality-of-life and reduced costs compared to routine OAC.
- These findings suggest a potential revision of current Canadian guidelines for atrial fibrillation management post-cardioversion.
Purpose:
Canadian guidelines suggest that physicians should consider prescribing four weeks of oral anticoagulation (OAC) for patients undergoing cardioversion for acute atrial fibrillation/flutter (AF/AFL), regardless of stroke risk. While the risk of stroke following cardioversion may be low, the morbidity and cost from a stroke is significant. This study aims to evaluate the cost-effectiveness of routinely providing OAC after cardioversion.
Methods:
We conducted a cost-utility analysis comparing no-OAC post-cardioversion to four weeks of OAC, from the perspective of the Canadian public payer, in adults with acute AF/AFL and no risk factors based on the CCS Algorithm (CHADS-65). A decision tree was used to estimate clinical outcomes, quality-of-life, and costs. Results were expressed as quality-adjusted life days and an incremental net monetary benefit. We performed a probabilistic sensitivity analysis using 10,000 Monte Carlo simulations to assess the robustness of our findings.
Results:
No-OAC was found to be dominant, with slightly increased quality-of-life (296 quality-adjusted life days vs. 295 quality-adjusted life days) at a lower cost [CAN$108.86 (95%CI $107.38-$110.34) vs. CAN$117.73 (95%CI $116.54-$118.91)] and an incremental net monetary benefit of $25.22 (95%CI $19.21-$31.23). A probabilistic sensitivity analysis showed the no-OAC option was cost-effective in 69.5% iterations. The results were driven by low event rates post-cardioversion.
Conclusion:
There were minimal differences between strategies and forgoing anticoagulation resulted in very slight improvement in quality-of-life at a reduced cost. We hope this provides guidance to physicians and look to see this evidence incorporated into Canadian guidelines for atrial fibrillation.
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