Author + information
- aDivision of Preventive Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- bCardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- cDivision of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- ↵∗Address for correspondence:
Dr. Christine M. Albert, Division of Preventive Medicine, Brigham and Women’s Hospital, 900 Commonwealth Avenue, Boston, Massachusetts 02215.
Atrial fibrillation (AF) care is expensive. The direct costs of AF care, including pharmacotherapy, outpatient visits, AF-related hospitalizations, and catheter ablation, have been estimated at $6 billion in the United States alone (1). Not included in those estimates are an additional $20 billion of indirect costs, which include other cardiovascular and noncardiovascular consequences of AF such as incident or worsening heart failure, bleeding, and cognitive dysfunction (2). The anticipated doubling of the global prevalence of AF over the next 2 decades (3) has only heightened the urgency to identify cost-effective strategies in the management of AF.
The rise in the age-adjusted incidence of AF has been accompanied by parallel increases in the prevalence of several modifiable risk factors including obesity, diabetes, and hypertension (4). In that context, there has been increasing focus on the role of risk factor modification (RFM) for the management and treatment of AF. Genetic (2) and randomized (5) data have provided the strongest evidence to date for a causal association between obesity and AF, and recent European guidelines include weight loss as a Class IIA recommendation for obese patients with AF (6). In addition to weight loss, a more broadly targeted RFM program inclusive of blood pressure and glucose control as well as lifestyle counseling (smoking, alcohol, diet) demonstrated compelling reductions in AF recurrence and improvements in quality of life in AF patients undergoing catheter ablation in a single-center study (7). Although other studies have explored the cost effectiveness of catheter ablation in AF (8), the combination of improved arrhythmia outcomes and quality of life coupled with potentially lower cost makes RFM programs a particularly appealing but untested cost-effective strategy for AF care.
In this issue of JACC: Clinical Electrophysiology, Pathak et al. (9) significantly advanced our understanding of the clinical and cost effectiveness of a dedicated RFM clinic for patients with AF (9). In an observational cohort of 355 patients from Adelaide, Australia, the authors compare clinical outcomes, health care utilization, and costs for patients who opted to participate in a dedicated RFM program (n = 208) with those of patients who did not (n = 147). Management of AF was undertaken by physicians blinded to study group. Using previously published estimates of quality of life utilities, they estimate 10-year cost savings associated with RFM in dollars saved per quality adjusted life year (QALY).
Overall, the RFM intervention was effective, with significant declines in systolic blood pressure (∼10 mm Hg vs. 3 mm Hg, respectively) and weight (∼10 kg vs. 3 kg, respectively), as well as a greater proportion demonstrating guideline-recommended control of lipids and glucose. Risk factor modification was associated with improved structural remodeling and reductions in AF frequency and duration. Over a median follow-up of approximately 4 years, 35% of the RFM group were free of AF, without the use of antiarrhythmic medications or catheter ablation, compared to only 18% in the control group. In those who underwent ablation, RFM remained associated with greater AF-free survival (79% vs. 44%, respectively). Health care utilization, with the exception of scheduled outpatient visits for RFM, was systematically lower in the RFM group. Rates of catheter ablation, cardioversion, emergency department visits, inpatient admissions, and unscheduled arrhythmia-related outpatient visits were all lower. Projected over 10 years, the authors estimate that RFM would save approximately AUD $60,000 per QALY gained.
Although the results are impressive and consistently robust in sensitivity analyses across a range of costs for noninvasive and invasive AF therapies, the findings need to be interpreted in the context of the study design and methodology used. First, the study population was composed of obese (median BMI: ∼33 kg/m2) patients without permanent AF (approximately one-half had paroxysmal AF), and the results may not be generalizable to other patient subgroups. Second, the use of an “opt-out” control group introduces the potential for selection bias, which could have influenced the results. Patients who choose not to participate in a noninvasive RFM strategy may exhibit a preference for an invasive strategy that involves ablation. Third, although the efficacy of RFM without ablation appears promising, annual ascertainment of AF in these patients almost certainly led to a systematic underestimation of AF recurrence, likely overestimating the efficacy of RFM and making direct comparison with previous reports of AF interventions challenging.
As the authors acknowledge, all cost-effectiveness analyses require significant assumptions, and a few are worth highlighting. First, for modeling purposes, AF states were dichotomized (“free” vs. “not free”) as opposed to a more clinically relevant continuous spectrum of utilities based upon frequency and duration of AF recurrences. Second, transition probabilities (assessed annually) were fixed and extrapolated up to 10 years based upon study estimates from an average of 4 years of follow-up. This assumption may overestimate cost effectiveness if the RFM intervention does not have a sustained impact on risk factors in the long term or if the probability of transitioning back to “AF-free” declines with increasing episodes of recurrence. Third, in contrast to previous studies (8), it does not appear that complications associated with catheter ablation or side effects of antiarrhythmic drugs were explicitly considered, which might have underestimated the cost effectiveness of RFM. Finally, the authors appropriately focused on “direct” costs of AF-related hospitalizations, although this likely underestimates cost savings as hospitalizations related to other consequences of AF (e.g., heart failure exacerbations), or other health outcomes impacted by RFM are likely significant. Conversely, the costs attributed to the RFM program in the study only included costs for visits and diagnostic procedures. It should be emphasized that the authorship group represents a “center of excellence” in RFM, and at another center there may be significant “up-front” infrastructure and training costs associated with building a de novo RFM program.
Taken together, Pathak et al. (9) have offered a compelling argument in favor of integrating RFM into the routine care of our patients with AF. Importantly, RFM was not only cost effective as a “first step” in patients with AF but retained its cost effectiveness even after catheter ablation, highlighting its role across the AF spectrum. Practically, the integration of dedicated RFM clinics into AF care represents the challenge of implementation, requiring collaboration among cardiovascular specialists, internists, and allied health professionals. Convincing health care payers to invest in the initial costs of implementation and subsequent reimbursement for RFM programs will likely require further data from multicenter outcome studies and definitive evidence from randomized controlled trials. With the latter evidence, we may be able to consider RFM the “optimal medical therapy” for AF, reserving antiarrhythmic therapy and catheter ablation for those for whom a trial of RFM has “failed.” For now, based upon these and other data, incorporating RFM into our armamentarium of AF therapies appears to make good dollars and sense.
↵∗ Editorials published in JACC: Clinical Electrophysiology reflect the views of the authors and do not necessarily represent the views of JACC: Clinical Electrophysiology or the American College of Cardiology.
This work was supported by National Heart, Lung, and Blood Institute grant R01HL116690-1 to Dr. Albert. Dr. Chatterjee is supported by NHLBI grant T-32 HL-00757.
All authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Clinical Electrophysiology author instructions page.
- 2017 American College of Cardiology Foundation
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