scholarly journals Optimal Duration of Monitoring for Atrial Fibrillation in Cryptogenic Stroke: A Nonsystematic Review

2016 ◽  
Vol 2016 ◽  
pp. 1-10 ◽  
Author(s):  
Essa Hariri ◽  
Ahmad Hachem ◽  
Georges Sarkis ◽  
Samer Nasr
Keyword(s):  
Atrial Fibrillation ◽  
Cost Effectiveness ◽  
Cryptogenic Stroke ◽  
Monitoring Strategy ◽  
Detection Rates ◽  
Monitoring Strategies ◽  
Optimal Duration ◽  
Multiple Trials ◽  
The Cost ◽  
Recommended Guidelines

Atrial fibrillation (AF) is the most common form of cardiac arrhythmias and an independent risk factor for stroke. Despite major advances in monitoring strategies, clinicians tend to miss the diagnoses of AF and especially paroxysmal AF due mainly to its asymptomatic presentation and the rather limited duration dedicated for monitoring for AF after a stroke, which is 24 hours as per the current recommended guidelines. Hence, determining the optimal duration of monitoring for paroxysmal atrial fibrillation after acute ischemic stroke remains a matter of debate. Multiple trials were published in regard to this matter using both invasive and noninvasive monitoring strategies for different monitoring periods. The data provided by these trials showcase strong evidence suggesting a longer monitoring strategy beyond 24 hours is associated with higher detection rates of AF, with the higher percentage of patients detected consequently receiving proper secondary stroke prevention with anticoagulation and thus justifying the cost-effectiveness of such measures. Overall, we thus conclude that increasing the monitoring duration for AF after a cryptogenic stroke to at least 72 hours will indeed enhance the detection rates, but the cost-effectiveness of this monitoring strategy compared to longer monitoring durations is yet to be established.

scholarly journals Cost-Effectiveness of Extended Electrocardiogram Monitoring for Atrial Fibrillation After Stroke

Stroke ◽  
2020 ◽  
Vol 51 (7) ◽  
pp. 2244-2248 ◽  
Author(s):  
Derek S. Chew ◽  
Elissa Rennert-May ◽  
Eldon Spackman ◽  
Daniel B. Mark ◽  
Derek V. Exner
Keyword(s):  
Atrial Fibrillation ◽  
Cost Effectiveness ◽  
Standard Care ◽  
Cryptogenic Stroke ◽  
Cost Utility ◽  
Economic Evaluations ◽  
Ecg Monitoring ◽  
The Cost ◽  
Monitoring Devices ◽  
Rhythm Monitoring

Background and Purpose: Management of cryptogenic stroke involves the identification of modifiable risk factors, such as atrial fibrillation (AF). Extended rhythm monitoring increases AF detection rates but at an increased device cost compared with conventional Holter monitoring. The objective of the study was to identify and synthesize the existing literature on the cost-effectiveness of prolonged rhythm monitoring devices for AF detection in cryptogenic stroke. Methods: We conducted a systematic review of available economic evaluations of prolonged ECG monitoring for AF detection following cryptogenic stroke compared with standard care. Results: Of the 530 unique citations, 8 studies assessed the cost-utility of prolonged ECG monitoring compared with standard care following cryptogenic stroke. The prolonged ECG monitoring strategies included 7-day ambulatory monitoring, 30-day external loop recorders or intermittent ECG monitoring, and implantable loop recorders. The majority of cost-utility analyses reported incremental cost-effectiveness ratios below $50 000 per QALY gained; and two studies reported a cost-savings. Conclusions: There is limited economic literature on the cost-effectiveness of extended ECG monitoring devices for detection of atrial fibrillation in cryptogenic stroke. In patients with cryptogenic stroke, extended ECG monitoring for AF detection may be economically attractive when traditional willingness-to-pay thresholds are adopted. However, there was substantial variation in the reported ICERs. The direct comparison of cost-effectiveness across technologies is limited by heterogeneity in modeling assumptions.

scholarly journals Cost-Effectiveness Analysis of BCG Vaccination against Tuberculosis in Indonesia: A Model-Based Study

Vaccines ◽  
2020 ◽  
Vol 8 (4) ◽  
pp. 707
Author(s):  
Afifah Machlaurin ◽  
Franklin Christiaan Karel Dolk ◽  
Didik Setiawan ◽  
Tjipke Sytse van der Werf ◽  
Maarten J. Postma
Keyword(s):  
Cost Effectiveness ◽  
Univariate Analysis ◽  
Cost Effective ◽  
Epidemiological Data ◽  
Control Programme ◽  
Detection Rates ◽  
Middle Income ◽  
Bcg Vaccination ◽  
Life Years ◽  
The Cost

Bacillus Calmette–Guerin (BCG), the only available vaccine for tuberculosis (TB), has been applied for decades. The Indonesian government recently introduced a national TB disease control programme that includes several action plans, notably enhanced vaccination coverage, which can be strengthened through underpinning its favourable cost-effectiveness. We designed a Markov model to assess the cost-effectiveness of Indonesia’s current BCG vaccination programme. Incremental cost-effectiveness ratios (ICERs) were evaluated from the perspectives of both society and healthcare. The robustness of the analysis was confirmed through univariate and probabilistic sensitivity analysis (PSA). Using epidemiological data compiled for Indonesia, BCG vaccination at a price US$14 was estimated to be a cost-effective strategy in controlling TB disease. From societal and healthcare perspectives, ICERs were US$104 and US$112 per quality-adjusted life years (QALYs), respectively. The results were robust for variations of most variables in the univariate analysis. Notably, the vaccine’s effectiveness regarding disease protection, vaccination costs, and case detection rates were key drivers for cost-effectiveness. The PSA results indicated that vaccination was cost-effective even at US$175 threshold in 95% of cases, approximating the monthly GDP per capita. Our findings suggest that this strategy was highly cost-effective and merits prioritization and extension within the national TB programme. Our results may be relevant for other high endemic low- and middle-income countries.

The cost-effectiveness of one-time opportunistic screening for atrial fibrillation in different age cohorts of inhabitants in Denmark aged 65 years and above: a Markov modelled analysis

2020 ◽  
Author(s):  
Lucca Katrine Sciera ◽  
Lars Frost ◽  
Lars Dybro ◽  
Peter Bo Poulsen
Keyword(s):  
Atrial Fibrillation ◽  
General Practice ◽  
Cost Effectiveness ◽  
Incremental Cost ◽  
Population Data ◽  
National Registry ◽  
Opportunistic Screening ◽  
Age Cohorts ◽  
Life Years ◽  
The Cost

Abstract Aims The objective was to evaluate the cost-effectiveness of one-time opportunistic screening for atrial fibrillation (AF) in general practice in citizens aged ≥65 years in Denmark compared to a no-screening alternative following current Danish practice. Methods and results A decision tree and a Markov model were designed to simulate costs and quality-adjusted life years (QALYs) in a hypothetical cohort of citizens aged ≥65 years equivalent to the Danish population (1 M citizens) over the course of 19 years, using a healthcare and societal perspective. Share of detected AF patients following opportunistic screening was retrieved from a recent Danish screening study, whereas the risk stroke and bleedings in AF patients were based on population data from national registries and their associated costs was obtained from published national registry studies. The present study showed that one-time opportunistic screening for AF was more costly, but also more effective compared to a no-screening alternative. The analysis predicts that one-time opportunistic screening of all Danes aged ≥65 years potentially can identify an additional 10 300 AF patients and prevent 856 strokes in the period considered. The incremental cost of such a screening programme is €56.4 M, with a total gain of 6000 QALYs, resulting in an incremental cost-effectiveness ratio of €9400 per QALY gained. Conclusion Opportunistic screening in general practice in citizens aged ≥65 years in Denmark is cost-effective compared to a willingness-to-pay threshold of €22 000. The study and its findings support a potential implementation of opportunistic screening for AF at the general practitioner level in Denmark.

scholarly journals Predictors of Occult Paroxysmal Atrial Fibrillation in Cryptogenic Strokes Detected by Long-Term Noninvasive Cardiac Monitoring

2011 ◽  
Vol 2011 ◽  
pp. 1-5 ◽  
Author(s):  
Archit Bhatt ◽  
Arshad Majid ◽  
Anmar Razak ◽  
Mounzer Kassab ◽  
Syed Hussain ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Paroxysmal Atrial Fibrillation ◽  
Cryptogenic Stroke ◽  
Cardiac Monitoring ◽  
High Signal ◽  
Detection Rates ◽  
Non Invasive ◽  
Patient Reported ◽  
Premature Beats

Background and Purpose. Paroxysmal Atrial fibrillation/Flutter (PAF) detection rates in cryptogenic strokes have been variable. We sought to determine the percentage of patients with cryptogenic stroke who had PAF on prolonged non-invasive cardiac monitoring.Methods and Results. Sixty-two consecutive patients with stroke and TIA in a single center with a mean age of 61 (+/− 14) years were analyzed. PAF was detected in 15 (24%) patients. Only one patient reported symptoms of shortness of breath during the episode of PAF while on monitoring, and 71 (97%) of these 73 episodes were asymptomatic. A regression analysis revealed that the presence of PVCs (ventricular premature beats) lasting more than 2 minutes (OR 6.3, 95% CI, 1.11–18.92;P=.042) and strokes (high signal on Diffusion Weighted Imaging) (OR 4.3, 95% CI, 5–36.3;P=.041) predicted PAF. Patients with multiple DWI signals were more likely than solitary signals to have PAF (OR 11.1, 95% CI, 2.5–48.5,P<.01).Conclusion. Occult PAF is common in cryptogenic strokes, and is often asymptomatic. Our data suggests that up to one in five patients with suspected cryptogenic strokes and TIAs have PAF, especially if they have PVCs and multiple high DWI signals on MRI.

scholarly journals Use of mHealth Devices to Screen for Atrial Fibrillation: Cost-Effectiveness Analysis (Preprint)

2020 ◽  
Author(s):  
Godwin D Giebel
Keyword(s):  
Atrial Fibrillation ◽  
Cost Effectiveness ◽  
Economic Burden ◽  
Health Care Systems ◽  
Anticoagulation Therapy ◽  
Risk Scores ◽  
Increased Risk ◽  
Care Systems ◽  
Additional Costs ◽  
The Cost

BACKGROUND With an estimated prevalence of around 3% and an about 2.5-fold increased risk of stroke, atrial fibrillation (AF) is a serious threat for patients and a high economic burden for health care systems all over the world. Patients with AF could benefit from screening through mobile health (mHealth) devices. Thus, an early diagnosis is possible with mHealth devices, and the risk for stroke can be markedly reduced by using anticoagulation therapy. OBJECTIVE The aim of this work was to assess the cost-effectiveness of algorithm-based screening for AF with the aid of photoplethysmography wrist-worn mHealth devices. Even if prevented strokes and prevented deaths from stroke are the most relevant patient outcomes, direct costs were defined as the primary outcome. METHODS A Monte Carlo simulation was conducted based on a developed state-transition model; 30,000 patients for each CHA<sub>2</sub>DS<sub>2</sub>-VASc (Congestive heart failure, Hypertension, Age≥75 years, Diabetes mellitus, Stroke, Vascular disease, Age 65-74 years, Sex category [female]) score from 1 to 9 were simulated. The first simulation served to estimate the economic burden of AF without the use of mHealth devices. The second simulation served to simulate the economic burden of AF with the use of mHealth devices. Afterwards, the groups were compared in terms of costs, prevented strokes, and deaths from strokes. RESULTS The CHA<sub>2</sub>DS<sub>2</sub>-VASc score as well as the electrocardiography (ECG) confirmation rate had the biggest impact on costs as well as number of strokes. The higher the risk score, the lower were the costs per prevented stroke. Higher ECG confirmation rates intensified this effect. The effect was not seen in groups with lower risk scores. Over 10 years, the use of mHealth (assuming a 75% ECG confirmation rate) resulted in additional costs (€1=US $1.12) of €441, €567, €536, €520, €606, €625, €623, €692, and €847 per patient for a CHA<sub>2</sub>DS<sub>2</sub>-VASc score of 1 to 9, respectively. The number of prevented strokes tended to be higher in groups with high risk for stroke. Higher ECG confirmation rates led to higher numbers of prevented strokes. The use of mHealth (assuming a 75% ECG confirmation rate) resulted in 25 (7), –68 (–54), 98 (–5), 266 (182), 346 (271), 642 (440), 722 (599), 1111 (815), and 1116 (928) prevented strokes (fatal) for CHA<sub>2</sub>DS<sub>2</sub>-VASc score of 1 to 9, respectively. Higher device accuracy in terms of sensitivity led to even more prevented fatal strokes. CONCLUSIONS The use of mHealth devices to screen for AF leads to increased costs but also a reduction in the incidence of stroke. In particular, in patients with high CHA<sub>2</sub>DS<sub>2</sub>-VASc scores, the risk for stroke and death from stroke can be markedly reduced.

scholarly journals Cost-effectiveness of catheter ablation versus medical therapy for the treatment of atrial fibrillation in the United Kingdom

EP Europace ◽  
2021 ◽  
Vol 23 (Supplement_3) ◽  
Author(s):  
L Leung ◽  
RJ Imhoff ◽  
D Frame ◽  
PJ Mallow ◽  
L Goldstein ◽  
...  
Keyword(s):  
Heart Failure ◽  
Atrial Fibrillation ◽  
Cost Effectiveness ◽  
Catheter Ablation ◽  
Medical Therapy ◽  
Rhythm Control ◽  
Uk National Health Service ◽  
The Uk ◽  
The Cost ◽  
Af Recurrence

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): This research study was funded by Biosense Webster, Inc. Dr Leung has received research support from Attune Medical (Chicago, IL) towards a research fellowship at St. George"s University of London. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed. Background Randomised data on patient-related outcomes comparing catheter ablation to medical therapy for the treatment of atrial fibrillation (AF) have shown the effectiveness of catheter ablation. Ablation versus medical therapy should also be analysed from a health economics perspective to achieve optimal healthcare resource allocation. Purpose To determine the cost effectiveness of catheter ablation compared to medical therapy for the treatment of atrial fibrillation, from the perspective of the UK National Health Service. Methods A patient-level Markov health-state transition model was used to conduct a cost utility analysis comparing catheter ablation and medical therapy for the treatment of AF. A systematic review and meta-analysis of catheter ablation treatment versus medical therapy (rhythm and/or rate control drugs) was conducted to enable comparison of AF recurrence between treatment groups utilising the model. Additional model parameters were established based upon a best-evidence review of the literature. The model simulated care delivered from a secondary care perspective. Total patients simulated in this model over a lifetime were 250,000, with patients entering the model at age 64. Only previously treated AF patients were included, including those with concomitant heart failure. A separate scenario analysis was conducted to determine the cost effectiveness specifically in the cohort of patients with AF and heart failure. Main outcomes measures Incremental cost-effectiveness ratio (ICER) and average total expected costs and quality-of-life years (QALYs) incurred over the lifetime of a patient. AF recurrence, complications and cardiovascular adverse events were compared over the total duration inside the model. Results In the base case analysis, catheter ablation resulted in a favourable ICER of £8,614 per additional QALY gained when compared to medical therapy, well below the national Willingness-to-Pay threshold of £20,000. Catheter ablation was associated with an expected increase of 1.01 QALYs, while adding an additional cost £8,742 over a patient’s lifetime. The cost-effectiveness of catheter ablation was improved in the heart failure sub-group analysis, with an ICER of £6,438. A significantly greater proportion of patients in the medical therapy group failed rhythm control at any stage compared to catheter ablation (72% vs 24%) and at a faster rate (median time to treatment failure: 3.8 vs 10 years). Conclusion Catheter ablation appears to be a highly cost-effective treatment for atrial fibrillation, compared to medical therapy, from the perspective of the UK National Health Service. With low rates of adverse events and superiority in achieving rhythm control, AF ablation services should be prioritised with appropriate allocation of healthcare resources.

Abstract 200: Cost-Effectiveness of Newer Anticoagulants for Stroke Prevention in Atrial Fibrillation

2013 ◽  
Vol 6 (suppl_1) ◽  
Author(s):  
Brendan L Limone ◽  
William L Baker ◽  
Craig I Coleman
Keyword(s):  
Atrial Fibrillation ◽  
Cost Effectiveness ◽  
Stroke Prevention ◽  
Indirect Comparison ◽  
Cost Effective ◽  
The United States ◽  
Base Case ◽  
Treatment Comparison ◽  
Newer Anticoagulants ◽  
The Cost

Background: A number of new anticoagulants for stroke prevention in atrial fibrillation (SPAF) have gained regulatory approval or are in late-stage development. We sought to conduct a systematic review of economic models of dabigatran, rivaroxaban and apixaban for SPAF. Methods: We searched the Medline, Embase, National Health Service Economic Evaluation Database and Health Technology Assessment database along with the Tuft’s Registry through October 10, 2012. Included models assessed the cost-effectiveness of dabigatran (150mg, 110mg, sequential), rivaroxaban or apixaban for SPAF using a Markov model or discrete event simulation and were published in English. Results: Eighteen models were identified. All models utilized a lone randomized trial (or an indirect comparison utilizing a single study for any given direct comparison), and these trials were clinically and methodologically heterogeneous. Dabigatran 150mg was assessed in 9 of models, dabigatran 110mg in 8, sequential dabigatran in 9, rivaroxaban in 4 and apixaban in 4. Adjusted-dose warfarin (either trial-like, real-world prescribing or genotype-dosed) was a potential first-line therapy in 94% of models. Models were conducted from the perspective of the United States (44%), European countries (39%) and Canada (17%). In base-case analyses, patients typically were at moderate-risk of ischemic stroke, initiated anticoagulation between 65 and 73 years of age, and were followed for or near a lifetime. All models reported cost/quality-adjusted life-year (QALY) gained, and while 22% of models reported using a societal perspective, no model included costs of lost productivity. Four models reported an incremental cost-effectiveness ratio (ICER) for a newer anticoagulant (dabigatran 110mg (n=4)/150mg (n=2); rivaroxaban (n=1)) vs. warfarin above commonly reported willingness-to-pay thresholds. ICERs (in 2012US$) vs. warfarin ranged from $3,547-$86,000 for dabigatran 150mg, $20,713-$150,000 for dabigatran 110mg, $4,084-$21,466 for sequentially-dosed dabigatran and $23,065-$57,470 for rivaroxaban. In addition, apixaban was demonstrated to be an economically dominant strategy compared to aspirin and to be dominant or cost-effective ($11,400-$25,059) vs. warfarin. Based on separate indirect treatment comparison meta-analyses, 3 models compared the cost-effectiveness of these new agents and reported conflicting results. Conclusions: Cost-effectiveness models of newer anticoagulants for SPAF have been extensively published. Models have frequently found newer anticoagulants to be cost-effective, but due to the lack of head-to-head trial comparisons and heterogeneity in clinical characteristic of underlying trials and modeling methods, it is currently unclear which of these newer agents is most cost-effective.

scholarly journals A Systematic Literature Review on the Cost-Effectiveness of Apixaban for Stroke Prevention in Non-valvular Atrial Fibrillation

2016 ◽  
Vol 5 (2) ◽  
pp. 171-186 ◽  
Author(s):  
Carme Pinyol ◽  
Jose Mª Cepeda ◽  
Inmaculada Roldan ◽  
Vanesa Roldan ◽  
Silvia Jimenez ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Cost Effectiveness ◽  
Literature Review ◽  
Systematic Literature Review ◽  
Stroke Prevention ◽  
The Cost

Cost-effectiveness analysis for preventing hepatitis B virus reactivation-related death in Japan

2020 ◽  
Vol 30 (Supplement_5) ◽  
Author(s):  
M Fujita ◽  
S Kusumoto ◽  
M Sugiyama ◽  
T Fujisawa ◽  
M Mizokami ◽  
...  
Keyword(s):  
Cost Effectiveness ◽  
Cost Effective ◽  
Cost Effectiveness Analysis ◽  
Hbv Dna ◽  
Hbv Reactivation ◽  
Monitoring Strategy ◽  
Effectiveness Analysis ◽  
B Virus ◽  
Tenofovir Alafenamide ◽  
The Cost

Abstract Background There is no worldwide standard recommendation for preventing hepatitis B virus (HBV) reactivation for patients with resolved infection treated with an anti-CD20 antibody for B-cell non-Hodgkin lymphoma. This study aims to compare the cost-effectiveness between two commonly used strategies to prevent HBV reactivation-related death. Methods The two strategies compared were prophylactic antiviral therapy (Pro NAT) and HBV DNA monitoring followed by on-demand antiviral therapy (HBV DNA monitoring) using entecavir (Entecavir, a generic drug for Baraclude). Effectiveness was defined as the prevention of death due to HBV reactivation and costs were calculated under the health insurance system of Japan as of April 2018 using Markov model. A cost-minimization analysis, one of the cost-effectiveness analyses, was applied, since the effectiveness was the same between the two strategies according to a meta-analysis. To consider the effect of uncertainty for each parameter, probabilistic sensitivity analysis (PSA) was performed. In the scenario analysis, costs were calculated using lamivudine (Zefix) or tenofovir alafenamide (Vemlidy) instead of entecavir. All analyses were done using TreeAge Pro 2019 (TreeAge Software, Inc., MA, USA). Results Estimated costs per patient during the 30 months after initiation of chemotherapy for lymphoma were 1,513 USD with Pro NAT and 1,265 USD with HBV DNA monitoring. A PSA revealed that HBV DNA monitoring was more consistently cost-effective compared with Pro NAT when some parameters were set randomly according to probability distributions. In our scenario analysis, costs of Pro NAT and HBV DNA monitoring were calculated as 2,762 and 1,401 USD using lamivudine, 4,857 and 1,629 USD using tenofovir alafenamide. Conclusions Our cost-effectiveness analysis shows that an HBV DNA monitoring strategy using entecavir should be recommended for preventing HBV reactivation-related death in Japan. Key messages Cost-effectiveness analysis demonstrated that HBV DNA monitoring was more cost-effective compared to Pro NAT; this result was consistent with PSA. HBV DNA monitoring strategy should be recommended to prevent HBV reactivation-related death for the patients with resolved HBV infection in Japan.

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