THE COST-EFFECTIVENESS OF RADIOFREQUENCY CATHETER ABLATION FOR THE TREATMENT OF ATRIAL FIBRILLATION: RESULTS FROM A BAYESIAN EVIDENCE SYNTHESIS AND VALUE OF INFORMATION ANALYSIS

   Purpose: To assess the cost-effectiveness and value of information of radiofrequency catheter ablation (RFCA) compared with anti-arrhythmic drug (AAD) therapy for the treatment of atrial fibrillation (AF) from the perspective of the UK NHS.       Methods: A probabilistic model was constructed to estimate costs and quality-adjusted life years (QALYs) of RFCA compared to long-term AADs. A short-term decision tree was used to model costs and events during the initial 12-months (reflecting the time-horizon of the RCTs) and a Markov structure was employed for the lifetime extrapolation. Given the limited RCT evidence base identified and concerns regarding the generalisabillity of this evidence to routine practice (i.e. RCTs were mainly undertaken in pioneering centres), Bayesian meta-analytic approaches were employed to synthesise the results of RCTs with wider evidence from observational studies. Heterogeneity was explicitly modelled and cost-effectiveness was estimated for patients with different baseline risks of stroke (defined according to CHADS2 risk scores). Decision uncertainty was used to inform future research priorities using value of information (VOI) analysis.

   Results: The incremental cost-effectiveness ratio (ICER) of RFCA varied between £7,763 and £7,910 per additional QALY according to different baseline risks of stroke, with an associated probability of being cost-effective from 0.98 to 0.99 (threshold of £20,000). Applying shorter duration of quality of life benefits (5-years as opposed to a lifetime) resulted in marked increases in the ICERs (between £20,831 and £27,745 per QALY for the different CHADs scores). For shorter durations of quality of life benefits, the cost-effectiveness of RFCA was also dependant on a number of factors, including: (i) the prognostic benefits associated with restoration of normal sinus rhythm; (ii) the magnitude of any quality of life differences between RFCA and AADs and (iii) the long-term reduction in risk of recurrent AF. The results of the VOI analysis highlighted that future research would be of most value directed toward obtaining more precise estimates of the quality of life of benefits of RFCA (in relation to the size and the duration).

   Conclusions: RFCA appears cost-effective for the treatment of paroxysmal AF in patients’ predominantly refractory to AAD therapy provided the quality of life benefits from treatment are maintained for at minimum of 5 years. Further research appears valuable in establishing the long term quality of life benefits of RFCA