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LAA closure may save costs vs. anticoagulation in AF
At 10 years, left atrial appendage closure with an FDA-approved device was associated with cost savings compared with anticoagulation in patients with nonvalvular atrial fibrillation requiring stroke prevention, according to an economic analysis.
Vivek Y. Reddy, MD, director of cardiac arrhythmia services for The Mount Sinai Hospital and the Mount Sinai Health System and the Leona M. and Harry B. Helmsley Charitable Trust Professor of Medicine in Cardiac Electrophysiology at Icahn School of Medicine at Mount Sinai, and colleagues analyzed the cost-effectiveness of use of the LAA closure device (Watchman, Boston Scientific) compared with warfarin and non-vitamin K antagonist oral anticoagulants.
Cost analysis
“Left atrial appendage closure is not a trivial cost, and drugs don’t cost as much, but you have to take a drug for the rest of your life, which adds up over time,” Reddy told Cardiology Today. “Cost-effectiveness analyses are important for us to make decisions about what we do to treat patients.”
Reddy and colleagues constructed a Markov model with a lifetime (20-year) horizon from a U.S. payer perspective. Clinical event rates and stroke outcomes from the LAA closure population were taken from 5-year data of the PROTECT AF and PREVAIL randomized controlled trials. Clinical outcomes related to anticoagulant use were taken from meta-analyses and randomized controlled trials.
The model included 10,000 patients with a mean age of 70 years and moderate risk for stroke and bleeding.
“One of the unique things we did is that most cost analyses just look at a 20- or 30-year time horizon, but in addition, we also showed costs as a function of time, so we could see what happens over the course of 20 years, and when we reached cost-effectiveness and dominance,” Reddy said in an interview.
Compared with warfarin, LAA closure was cost-effective by the seventh year (cost per quality-adjusted-life year, $48,674) and dominant, defined as both more effective and less costly, by the 10th year, according to the researchers.
Compared with non-vitamin K antagonist oral anticoagulants, LAA closure was less expensive ($23,960 vs. $25,691) and dominant by the fifth year, Reddy and colleagues wrote.
Over the lifetime (20-year) span, LAA closure was associated with 0.6 more QALYs compared with warfarin and 0.29 more QALYs compared with non-vitamin K antagonist oral anticoagulants, according to the researchers.
Economic impact
“One of the things I learned is that, over time, the cost is really driven by strokes,” Reddy told Cardiology Today. “Stroke is what causes the biggest impact to the health care system, and not all strokes have the same economic impact. As you might imagine, strokes that cause a greater amount of disability have a greater economic impact.”
In a sensitivity analysis, LAA closure was cost-effective compared with warfarin in 98% of simulations and cost-effective compared with non-vitamin K antagonist oral anticoagulants in 95% of simulations.
“What this tells clinicians is that the Watchman is not only cost-effective, it is cost-saving, certainly compared to warfarin and perhaps compared to [non-vitamin K antagonist oral anticoagulants] if they look across trials,” Reddy said in an interview. “But the reality is, most physicians make decisions based on individual patients. This analysis is helpful for payers, insurance companies and regulatory agencies because this information is very important for them. For individual physicians, it’s more about a feeling of comfort that they will not bankrupt the health system if they choose LAA closure.” – by Erik Swain
For more information:
Vivek Y. Reddy, MD, can be reached at Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029; email: vivek.reddy@mountsinai.org.
Disclosures: The study was funded by Boston Scientific. Reddy reports he consults for and receives grants from Abbott, Biosense Webster and Boston Scientific. Three other authors report they consult for Boston Scientific. Another author reports she is employed by Boston Scientific.