Duke Clinical Research Institute, Duke University, Durham, NC (D.S.C., Z.L., M.F., A.L., J.A.R., A.D.D., D.B.M., J.P.P.).
Division of Cardiology (Z.L., M.F., A.L., J.A.R., B.D.A., A.D.D., D.B.M., J.P.P.), Duke University Medical Center, Durham, NC.
Circ Cardiovasc Qual Outcomes. 2020 Dec;13(12):e007094. doi: 10.1161/CIRCOUTCOMES.120.007094. Epub 2020 Dec 7.
Randomized clinical trials have demonstrated that catheter ablation for atrial fibrillation in patients with heart failure with reduced ejection fraction may improve survival and other cardiovascular outcomes.
We constructed a decision-analytic Markov model to estimate the costs and benefits of catheter ablation and medical management in patients with symptomatic heart failure with reduced ejection fraction (left ventricular ejection fraction ≤35%) and atrial fibrillation over a lifetime horizon. Evidence from the published literature informed the model inputs, including clinical effectiveness data from meta-analyses. Probabilistic and deterministic sensitivity analyses were performed. A 3% discount rate was applied to both future costs and benefits. The primary outcome was the incremental cost-effectiveness ratio assessed from the US health care sector perspective.
Catheter ablation was associated with 6.47 (95% CI, 5.89-6.93) quality-adjusted life years (QALYs) and a total cost of $105 657 (95% CI, $55 311-$191 934; 2018 US dollars), compared with 5.30 (95% CI, 5.20-5.39) QALYs and $63 040 (95% CI, $37 624-$102 260) for medical management. The incremental cost-effectiveness ratio for catheter ablation compared with medical management was $38 496 (95% CI, $5583-$117 510) per QALY gained. Model inputs with the greatest variation on incremental cost-effectiveness ratio estimates were the cost of ablation and the effect of catheter ablation on mortality reduction. When assuming a more conservative estimate of the treatment effect of catheter ablation on mortality (hazard ratio of 0.86), the estimated incremental cost-effectiveness ratio was $74 403 per QALY gained. At a willingness-to-pay threshold of $100 000 per QALY gained, atrial fibrillation ablation was found to be economically favorable compared with medical management in 95% of simulations.
Catheter ablation in patients with heart failure with reduced ejection fraction patients and atrial fibrillation may be considered economically attractive at current benchmarks for societal willingness-to-pay in the United States.
随机临床试验表明，对于射血分数降低的心力衰竭合并心房颤动患者，导管消融术可能改善生存和其他心血管结局。
我们构建了一个决策分析马尔可夫模型，以估计在具有射血分数降低（左心室射血分数≤35%）和心房颤动的有症状心力衰竭患者的一生中，导管消融术和药物治疗的成本和效益。来自已发表文献的证据为模型输入提供了信息，包括荟萃分析的临床疗效数据。进行了概率和确定性敏感性分析。对未来的成本和效益应用了 3%的贴现率。主要结果是从美国医疗保健部门的角度评估的增量成本效益比。
与药物治疗相比，导管消融术可获得 6.47 个（95%CI，5.89-6.93）质量调整生命年（QALY）和 105657 美元（95%CI，55311-191934 美元；2018 年美元）的总成本，而药物治疗可获得 5.30 个（95%CI，5.20-5.39）QALY 和 63040 美元（95%CI，37624-102260 美元）。与药物治疗相比，导管消融术的增量成本效益比为每获得一个 QALY 增加 38496 美元（95%CI，5583-117510 美元）。对增量成本效益比估计影响最大的模型输入是消融术的成本和导管消融术对死亡率降低的影响。当假设导管消融术对死亡率的治疗效果更保守的估计（风险比为 0.86）时，估计的增量成本效益比为每获得一个 QALY 增加 74403 美元。在 100000 美元/QALY 获得的意愿支付阈值下，在 95%的模拟中，与药物治疗相比，心房颤动消融术在经济上更具吸引力。
对于射血分数降低的心力衰竭合并心房颤动患者，导管消融术可能在目前美国社会愿意支付的基准下具有经济吸引力。
