Cost-Effectiveness of Rhythm versus Rate Control in Atrial Fibrillation

  1. Deborah A. Marshall, PhD;
  2. Adrian R. Levy, PhD;
  3. Humberto Vidaillet, MD;
  4. Elisabeth Fenwick, PhD;
  5. April Slee;
  6. Gordon Blackhouse, MSc;
  7. H. Leon Greene, MD;
  8. D. George Wyse, MD, PhD;
  9. Graham Nichol, MD;
  10. Bernie J. O'Brien, PhD†; and
  11. and the AFFIRM and CORE Investigators*
  1. From McMaster University and St. Joseph's Hospital, Hamilton, Ontario, Canada; University of British Columbia, Vancouver, British Columbia, Canada; Marshfield Clinic, Marshfield, Wisconsin; University of York, York, United Kingdom; Axio Research Corporation, Seattle, Washington; University of Calgary, Calgary, Alberta, Canada; and University of Ottawa, Ottawa, Ontario, Canada.

    Abstract

    Background: Atrial fibrillation is the most common type of sustained cardiac arrhythmia, but recent trials have identified no clear advantage of rhythm control over rate control. Consequently, economic factors often play a role in guiding treatment selection.

    Objective: To estimate the cost-effectiveness of rhythm-control versus rate-control strategies for atrial fibrillation in the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM).

    Design: Retrospective economic evaluation. Nonparametric bootstrapping was used to estimate the distribution of incremental costs and effects on the cost-effectiveness plane.

    Data Sources: Data on survival and use of health care resources were obtained for all 4060 AFFIRM participants. Unit costs were estimated from various U.S. databases.

    Target Population: Patients with atrial fibrillation who were 65 years of age or who had other risk factors for stroke or death, similar to those enrolled in AFFIRM.

    Time Horizon: Mean follow-up of 3.5 years.

    Perspective: Third-party payer.

    Interventions: Management of patients with atrial fibrillation with antiarrhythmic drugs (rhythm control) compared with drugs that control heart rate (rate control).

    Outcome Measures: Mean survival, resource use, costs, and cost-effectiveness.

    Results of Base-Case Analysis: A mean survival gain of 0.08 year (P = 0.10) was observed for rate control. Patients in the rate-control group used fewer resources (hospital days, pacemaker procedures, cardioversions, and short-stay and emergency department visits). Rate control costs $5077 less per person than rhythm control.

    Results of Sensitivity Analysis: Cost savings ranged from $2189 to $5481 per person. Rhythm control was more costly and less effective than rate control in 95% of the bootstrap replicates over a wide range of cost assumptions.

    Limitations: Resource use was limited to key items collected in AFFIRM, and the results are generalizable only to similar patient populations with atrial fibrillation.

    Conclusion: Rate control is a cost-effective approach to the management of atrial fibrillation compared with maintenance of sinus rhythm in patients with atrial fibrillation similar to those enrolled in AFFIRM.

    †Deceased.

    A complete list of the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) investigators has been published elsewhere (Am Heart J. 2002;143:991-1001).

    *For a list of the Cardiac Outcomes and Research in Economics (CORE) investigators, see the Appendix.

    Article and Author Information

    • Acknowledgments: The authors thank Mr. Tom Delea, Policy Analysis, Inc., for advice regarding costing. This paper is dedicated to our late mentor, colleague, coauthor, and friend, Bernie O'Brien.

    • Grant Support: AFFIRM was supported (contract N01-HC-55139) by the National Heart, Lung, and Blood Institute. The CORE study for the cost-effectiveness analysis is supported in part by the Canadian Institutes of Health Research Chronic Disease New Emerging Team Program, The Canadian Diabetes Association, The Kidney Foundation of Canada, the Heart and Stroke Foundation of Canada, and the Canadian Institutes of Health Research Institutes of Nutrition, Metabolism and Diabetes, Circulatory and Respiratory Health, and Gender and Health. Dr. Elisabeth Fenwick's postdoctoral fellowship was funded through a fellowship from Roche, Canada. Dr. Bernie J. O'Brien was supported by the Canadian Institutes of Health Research (CIHR). Dr. Graham Nichol is a Career Scientist of the Ontario Ministry of Health.

    • Potential Financial Conflicts of Interest: Consultancies: H. Vidaillet (Astra Zeneca); Honoraria: H. Vidaillet (Astra Zeneca); Grants received: G. Nichol (Medtronic Inc., Canadian Institutes of Health Research, Medtronic ERS, Cardiac Science, Zoll, Philips, National Heart, Lung, and Blood Institute); Grants pending: G. Nichol (Medtronic Inc., Medtronic ERS).

    • Requests for Single Reprints: Deborah Marshall, PhD, Center for Evaluation of Medicine, McMaster University, 25 Main Street West, Suite 2000, Hamilton, Ontario L6B 1H1, Canada; e-mail, marshd{at}mcmaster.ca.

    • Current Author Addresses: Dr. Marshall: Department of Clinical Epidemiology and Biostatistics, McMaster University, Centre for Evaluation of Medicines, 25 Main Street West, Suite 2000, Hamilton, Ontario L6B 1H1, Canada.

    • Dr. Levy: Department of Health Care and Epidemiology, University of British Columbia, St. Paul's Hospital, 620B-1081 Burrard Street, Vancouver, British Columbia V6Z 1Y6, Canada.

    • Dr. Vidaillet: Marshfield Clinic–Marshfield Center, 1000 North Oak Avenue, Marshfield, WI 54449.

    • Dr. Fenwick: Department of Economics and Related Studies and Centre for Health Economics, University of York, York Y0105DD, United Kingdom.

    • Ms. Slee and Dr. Greene: Axio Research Corporation, 2601 4th Avenue, Suite 200, Seattle, WA 98121.

    • Mr. Blackhouse: Program for Assessment of Technology in Health, McMaster University, 25 Main Street West, Suite 2000, Hamilton, Ontario L6B 1H1, Canada.

    • Dr. Wyse: Faculty of Medicine, University of Calgary, 3330 Hospital Drive Northwest, Calgary, Alberta T2N 4N1, Canada.

    • Dr. Nichol: University of Washington, Harborview Research and Training Center for Pre-Hospital Emergency Care, 325 Ninth Avenue, Seattle, WA 98104.

    • Author Contributions: Conception and design: D.A. Marshall, A.R. Levy, H. Vidaillet, E. Fenwick, D.G. Wyse, G. Nichol, B.J. O'Brien.

    • Analysis and interpretation of the data: D.A. Marshall, A.R. Levy, H. Vidaillet, E. Fenwick, A. Slee, G. Blackhouse, L. Greene, D.G. Wyse, G. Nichol, B.J. O'Brien.

    • Drafting of the article: D.A. Marshall, A.R. Levy, H. Vidaillet, D.G. Wyse, G. Nichol.

    • Critical revision of the article for important intellectual content: D.A. Marshall, A.R. Levy, H. Vidaillet, E. Fenwick, A. Slee, L. Greene, D.G. Wyse, G. Nichol, B.J. O'Brien.

    • Final approval of the article: D.A. Marshall, A.R. Levy, H. Vidaillet, E. Fenwick, D.G. Wyse, B.J. O'Brien.

    • Provision of study materials or patients: D.A. Marshall, H. Vidaillet, D.G. Wyse.

    • Statistical expertise: D.A. Marshall, A. Slee, G. Blackhouse.

    • Obtaining of funding: D.A. Marshall, A.R. Levy, L. Greene, D.G. Wyse.

    • Administrative, technical, or logistic support: D.A. Marshall.

    • Collection and assembly of data: D.A. Marshall, A.R. Levy, H. Vidaillet, L. Greene.

    Summary for Patients

    • Summaries for Patients:Cost-Effectiveness of Rate Control vs. Rhythm Control for Patients with Atrial Fibrillation Ann Intern Med November 2, 2004 141:I-20
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    1. Ann Intern Med November 2, 2004 vol. 141 no. 9 653-661
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