Purpose: To assess, the cost-effectiveness of pulmonary vein ablation compared to anti-arrhythmic drug (AAD) treatment for patients with paroxysmal atrial fibrillation (AF) having previously failed on an AAD in Canada.
Method: A probabilistic economic model was developed to compare two AF treatment strategies: 1) pulmonary vein ablation 2) AAD (amiodarone 200mg/day). At the end of the initial 12 month phase of the model, patients are classified as being either in normal sinus rhythm or with AF. The pooled probability of patients on AAD being in normal sinus rhythm after 12 months was estimated to be 0.26. The relative risk of being in normal sinus rhythm for patients receiving ablation compared to AAD (2.93) was estimated by pooling data from controlled randomized and non-randomized studies. The per patient ablation cost used in the model was $12,179 while the annual cost of AAD used was $433. In the long term Markov phase of the model, patients are at risk of ischemic stroke each 3 month model cycle. Increased costs, increased mortality and decreased quality of life were assinged to patients after suffering a stroke. Patients with AF were assumed to have a 1.6 times increased risk of stroke compared to patients in normal sinus rhythm. A disutility of 0.046 was applied to patients while in the AF health state during the long tore Markov model phase. These model parameters were derived from various literature sources.
Result: The model estimated that compared to the AAD strategy, ablation had $8,539 higher costs, 0.033 fewer strokes and 0.144 more QALYS over the 5 year time horizon. The incremental cost per QALY of ablation compared to AAD was estimated to be $59,194. The probability of ablation being cost effective for willingness to pay thresholds of $50,000 and $100,000 was estimated to be 0.89 and 0.90 respectively. Disutility of AF has a large impact on results. If the disutility while being in an AF health state is assumed to be 0.02 instead of 0.046, the cost per QALY of ablation became $101,083.
Conclusion: Based on current evidence, pulmonary vein ablation for treatment of AF is cost effective if decision makers willingness to pay for a QALY is $59,194 or higher. Cost-effectiveness results are sensitive to the disutility associated with AF.