Use of mHealth Devices to Screen for Atrial Fibrillation: Cost-Effectiveness Analysis

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 CHA2DS2-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 CHA2DS2-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 CHA2DS2-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 CHA2DS2-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 CHA2DS2-VASc scores, the risk for stroke and death from stroke can be markedly reduced.

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

10.2196/preprints.20496 ◽

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 CHA2DS2-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 CHA2DS2-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 CHA2DS2-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 CHA2DS2-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 CHA2DS2-VASc scores, the risk for stroke and death from stroke can be markedly reduced.

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The potential clinical and economic outcomes of pharmacogenetics-oriented management of warfarin therapy – a decision analysis

Thrombosis and Haemostasis ◽

10.1160/th04-03-0161 ◽

2004 ◽

Vol 92 (09) ◽

pp. 590-597 ◽

Cited By ~ 31

Author(s):

Fredric Chan ◽

Raymond Wong ◽

Gregory Cheng ◽

Joyce You

Keyword(s):

Cost Effectiveness ◽

Major Bleeding ◽

Marginal Cost ◽

Warfarin Therapy ◽

Anticoagulation Therapy ◽

Economic Outcomes ◽

Treatment Scheme ◽

Increased Risk ◽

The Cost ◽

Anticoagulation Service

SummaryVariant cytochrome P450 (CYP) 2C9 genotypes are associated with low maintenance dose requirement of warfarin therapy and increased risk of major bleeding events. The objective of the present study was to evaluate the potential clinical and economic outcomes of using CYP2C9 genotype data to guide the management of anticoagulation therapy and to identify influential factors affecting the cost-effectiveness of this treatment scheme. A decision tree was designed to simulate, over 12 months, the clinical and economic outcomes of patients newly started on warfarin associated with two alternatives: (1) no genotyping (non-genotyped group) and (2) CYP2C9 genotyping prior to initiation of warfarin therapy (genotyped group). Nongenotyped group patients would receive standard care of an anticoagulation clinic (AC). In the genotyped group, patients with at least one variant CYP2C9 allele would receive intensified anticoagulation service. Most of the clinical probabilities were derived from literature. The direct medical costs were estimated from the Diagnosis-Related Group charges and from literature. The total number of events and the direct medical cost per 100 patient-years in the genotyped and non-genotyped groups were 9.58 and USD155,700, and, 10.48 and USD 150,500, respectively. The marginal cost per additional major bleeding averted in the genotyped group was USD 5,778. The model was sensitive to the variation of the cost and reduction of bleeding rate in the intensified anticoagulation service. In conclusion, the pharmacogenetics-oriented management of warfarin therapy is potentially more effective in preventing bleeding with a marginal cost. The cost-effectiveness of this treatment scheme depends on the relative cost and effectiveness of a pharmacogenetics-oriented intensified anticoagulation service comparing to the standard AC care.

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How to assess the value of low-value care

BMC Health Services Research ◽

10.1186/s12913-020-05825-y ◽

2020 ◽

Vol 20 (1) ◽

Author(s):

José Antonio Sacristán

Keyword(s):

Health Care ◽

Cost Effectiveness ◽

Health Care Services ◽

Health Care Systems ◽

Effective Intervention ◽

Use Of Resources ◽

True Value ◽

Care Systems ◽

Definition Of ◽

The Cost

Abstract Background Many of the strategies designed to reduce “low-value care” have been implemented without a consensus on the definition of the term “value”. Most “low value care” lists are based on the comparative effectiveness of the interventions. Main text Defining the value of an intervention based on its effectiveness may generate an inefficient use of resources, as a very effective intervention is not necessarily an efficient intervention, and a low effective intervention is not always an inefficient intervention. The cost-effectiveness plane may help to differentiate between high and low value care interventions. Reducing low value care should include three complementary strategies: eliminating ineffective interventions that entail a cost; eliminating interventions whose cost is higher and whose effectiveness is lower than that of other options (quadrant IV); and eliminating interventions whose incremental or decremental cost-effectiveness is unacceptable in quadrants I and III, respectively. Defining low-value care according to the efficiency of the interventions, ideally at the level of subgroups and individuals, will contribute to develop true value-based health care systems. Conclusion Cost-effectiveness rather than effectiveness should be the main criterion to assess the value of health care services and interventions. Payment-for-value strategies should be based on the definition of high and low value provided by the cost-effectiveness plane.

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Systematic review of cost-effectiveness analyses of dabigatran versus warfarin for atrial fibrillation across different health care systems

Value in Health ◽

10.1016/j.jval.2013.03.1495 ◽

2013 ◽

Vol 16 (3) ◽

pp. A288

Author(s):

J. Jegathisawaran ◽

J.M. Bowen ◽

F. Khondoker ◽

K. Campbell ◽

N. Burke ◽

...

Keyword(s):

Atrial Fibrillation ◽

Systematic Review ◽

Health Care ◽

Cost Effectiveness ◽

Health Care Systems ◽

Care Systems

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Evaluation of the prognostic value of GDF-15, ABC-AF-bleeding score and ABC-AF-death score in patients with atrial fibrillation across different geographical areas

Open Heart ◽

10.1136/openhrt-2020-001471 ◽

2021 ◽

Vol 8 (1) ◽

pp. e001471

Author(s):

Tymon Pol ◽

Ziad Hijazi ◽

Johan Lindbäck ◽

John H Alexander ◽

M Cecilia Bahit ◽

...

Keyword(s):

Atrial Fibrillation ◽

Major Bleeding ◽

Prognostic Value ◽

Anticoagulation Therapy ◽

Risk Scores ◽

Death Risk ◽

Link Type ◽

Increased Risk ◽

Geographic Regions ◽

Bleeding Score

ObjectivesGrowth differentiation factor 15 (GDF-15) is a biomarker independently associated with bleeding and death in anticoagulated patients with atrial fibrillation (AF). GDF-15 is also used as one component in the more precise biomarker-based ABC (age, biomarkers, clinical history)-AF-bleeding and ABC-AF-death risk scores. Data from large trials indicate a geographic variability in regard to overall outcomes, including bleeding and mortality risk. Our aim was to assess the consistency of the association between GDF-15, ABC-AF-bleeding score and ABC-AF-death score, with major bleeding and death, across world geographic regions.MethodsData were available from 14 767 patients with AF from the Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation (ARISTOTLE) trial and 8651 patients with AF from the Randomized Evaluation of Long-Term Anticoagulation Therapy (RE-LY) trial in this cohort study. GDF-15 was analysed from plasma samples obtained at randomisation. The geographical consistency of the associations between outcomes and GDF-15, ABC-AF-bleeding score and ABC-AF-death scores were assessed by Cox-regression models including interactions with predefined geographical region.ResultsGDF-15 and the ABC-AF-bleeding score were associated with major bleeding in both trials across regions (p<0.0001). Similarly, GDF-15 and the ABC-AF-death score were associated with all-cause mortality in both trials across regions (p<0.0001). Overall, the association between GDF-15, the ABC-AF-bleeding score and ABC-AF-death risk score with major bleeding and death was consistent across regions in both ARISTOTLE and the RE-LY trial cohorts. The ABC-AF-bleeding and ABC-AF-death risk scores were consistent regarding discriminative ability when comparing geographic regions in both trial cohorts. The C-indices ranged from 0.649 to 0.760 for the ABC-AF-bleeding and from 0.677 to 0.806 for the ABC-AF-death score by different geographic regions.ConclusionsIn patients with AF on anticoagulation, GDF-15 and the biomarker-based ABC-AF-bleeding and ABC-AF-death risk scores are consistently associated with respectively increased risk of major bleeding and death and have similar prognostic value across world geographic regions.Trial registration numberClinicalTrials.gov Registry NCT00412984 and NCT00262600.

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Overcoming global challenges in stroke prophylaxis in atrial fibrillation: The role of non-vitamin K antagonist oral anticoagulants

International Journal of Stroke ◽

10.1177/1747493016660106 ◽

2016 ◽

Vol 11 (9) ◽

pp. 950-967 ◽

Cited By ~ 2

Author(s):

Ayrton Massaro ◽

Robert P Giugliano ◽

Bo Norrving ◽

Ali Oto ◽

Roland Veltkamp

Keyword(s):

Atrial Fibrillation ◽

Vitamin K ◽

Health Care Systems ◽

Vitamin K Antagonists ◽

Oral Anticoagulants ◽

Vitamin K Antagonist ◽

Ageing Population ◽

Maximum Benefit ◽

Increased Risk ◽

Care Systems

Atrial fibrillation is the world's most common sustained cardiac arrhythmia and is associated with a significantly increased risk of stroke. The global burden of atrial fibrillation is rising, commensurate with the ageing population. Well-controlled vitamin K antagonist-based anticoagulation has been shown to reduce the risk of stroke secondary to atrial fibrillation by two-thirds. However, patients with atrial fibrillation have frequently been denied anticoagulation because of a variety of perceived risks related to bleeding, falls, chronological age, and poor compliance. Even when vitamin K antagonists are used, maximum benefit and safety are only delivered when high quality control of therapy (TTR > 70%) is achieved, which has proven remarkably difficult in many health-care systems and amongst many patient groups. The non-vitamin K antagonist oral anticoagulants (NOACs) offer solutions to many of the challenges of achieving widespread, safe, and effective anticoagulation for stroke prophylaxis in atrial fibrillation, yet their uptake into routine clinical practice remains variable. The evidence supporting their more widespread use to overcome the challenges of stroke prophylaxis for atrial fibrillation is reviewed in this article.

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Cost-effectiveness of reduction mammaplasty

International Journal of Technology Assessment in Health Care ◽

10.1017/s0266462304001072 ◽

2004 ◽

Vol 20 (3) ◽

pp. 269-273 ◽

Cited By ~ 7

Author(s):

Andrew J. Taylor ◽

David Tate ◽

Yvonne Brandberg ◽

Lennart Blomqvist

Keyword(s):

Cost Effectiveness ◽

Low Cost ◽

Health Care Systems ◽

Reduction Mammaplasty ◽

Cost Effective ◽

Quality Adjusted Life Year ◽

Decision Makers ◽

Care Systems ◽

The Cost ◽

New Evidence

Objectives:The purpose of this study is to provide a comparison of the benefits of reduction mammaplasty (RM) for women with heavy breasts often termed macromastia or breast hypertrophy (BH) surgery. The rationale is to provide information to allow decision-makers to make judgments about the cost-effectiveness of this intervention and make comparisons with other interventions which are commonly undertaken within publicly financed health-care systems.Methods:Data from a previous outcomes study in Sweden is re-analyzed to derive quality of life measures, from which a mean level of benefit outcome is derived and a cost per quality-adjusted life year is calculated (cost per QALY).Results:The low Cost per QALY suggests that reduction mammaplasty is cost-effective when compared with other treatments which are commonly undertaken.Conclusions:The authors suggest that the evidence in favor of funding reduction mammaplasty is strong and that decision-makers review their policy in light of this new evidence.

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