Health Economics Research Group, Institute of Environment, Health and Societies, Brunel University, London, United Kingdom.
Health Economics Research Group, Institute of Environment, Health and Societies, Brunel University, London, United Kingdom; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada.
JACC Clin Electrophysiol. 2018 May;4(5):660-668. doi: 10.1016/j.jacep.2018.01.007. Epub 2018 Mar 28.
This analysis uses the data from the randomized controlled trial to assess the cost effectiveness of catheter ablation (n = 132) versus escalated antiarrhythmic therapy (n = 127).
For survivors of myocardial infarction with implantable cardioverter-defibrillator shocks despite antiarrhythmic drugs, the VANISH (Ventricular Tachycardia Ablation Versus Escalated Antiarrhythmic Drug Therapy in Ischemic Heart Disease) trial demonstrated improved clinical outcomes with catheter ablation compared with more aggressive antiarrhythmic pharmacotherapy.
Health care resource use and quality-of-life data were used to determine the cost effectiveness of catheter ablation. Published references were used to estimate costs (in 2015 Canadian dollars). The analysis was over 3 years, with a 5% discount rate. Adjustment was made for censoring and baseline utilities.
Ablation resulted in greater quality-adjusted life-years (QALYs) than escalated drug therapy did (1.63 vs. 1.49; difference: 0.14; 95% confidence interval [CI]: -0.20 to 0.46) and higher cost ($65,126 vs. $60,269; difference: $4,857; 95% CI: -$19,757 to $27,106); with an incremental cost per QALY gained for ablation versus escalated drug therapy of $34,057 primarily due to the initial costs of ablation, which were partially offset by the costs of subsequent ablations and adverse outcomes in the escalated drug therapy arm. For patients with amiodarone-refractory ventricular tachycardia, ablation dominated escalated drug therapy, with greater QALYs (1.48 vs. 1.26; difference: 0.22; 95% CI: -0.19 to 0.59) and lower costs ($67,614 vs. $68,383; difference: -$769; 95% CI: -$35,330 to $27,092). For those with sotalol-refractory ventricular tachycardia, ablation resulted in similar QALYs (1.90 vs. 1.90; difference: -0.00; 95% CI: -0.59 to 0.62) and higher costs ($60,455 vs. $45,033; difference: $15,422; 95% CI: -$10,968 to $48,555).
For the total trial population, results are suggestive that ablation is cost effective compared with escalation of drug therapy. This result was only manifest for the subgroup of patients whose qualifying arrhythmia occurred despite amiodarone.
本分析利用随机对照试验的数据，评估导管消融（n=132）与升级抗心律失常治疗（n=127）的成本效益。
对于植入式心脏复律除颤器电击后仍有心肌梗死后幸存者，VANISH（缺血性心脏病中室性心动过速消融与升级抗心律失常药物治疗）试验表明，与更积极的抗心律失常药物治疗相比，导管消融可改善临床结局。
使用医疗资源使用和生活质量数据来确定导管消融的成本效益。使用已发表的参考文献来估计成本（2015 年加拿大元）。分析时间为 3 年，贴现率为 5%。对删失和基线效用进行了调整。
消融组的质量调整生命年（QALY）优于升级药物治疗组（1.63 比 1.49；差值：0.14；95%置信区间[CI]：-0.20 至 0.46），且成本更高（65126 美元比 60269 美元；差值：4857 美元；95%CI：-19757 美元至 27106 美元）；与升级药物治疗相比，消融治疗每增加一个 QALY 的增量成本为 34057 美元，主要是由于消融的初始成本，而消融后的成本和升级药物治疗组的不良结果部分抵消了这些成本。对于胺碘酮难治性室性心动过速患者，消融术优于升级药物治疗，具有更高的 QALY（1.48 比 1.26；差值：0.22；95%CI：-0.19 至 0.59）和更低的成本（67614 美元比 68383 美元；差值：-769 美元；95%CI：-35330 美元至 27092 美元）。对于索他洛尔难治性室性心动过速患者，消融术导致 QALY 相似（1.90 比 1.90；差值：0.00；95%CI：-0.59 至 0.62），但成本更高（60455 美元比 45033 美元；差值：15422 美元；95%CI：-10968 美元至 48555 美元）。
对于整个试验人群，结果表明与升级药物治疗相比，消融术具有成本效益。这一结果仅适用于符合条件的心律失常尽管使用胺碘酮但仍发生的患者亚组。
