CABANA: Catheter ablation appears to be cost-effective in patients with AF
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An economic analysis indicates catheter ablation is cost-effective for patients with atrial fibrillation, especially for those who also have HF, according to new data from the CABANA trial.
As Healio previously reported, in the main results of the CABANA trial of 2,204 patients, in the intention-to-treat population, catheter ablation was not associated with improved clinical outcomes compared with medical therapy, but in on-treatment and per-protocol analyses, it was. Many patients crossed over from one treatment to the other during the study. Catheter ablation was associated with improvements in quality of life, AF burden and freedom from AF recurrence.
“Given the upfront costs of ablation relative to drug therapy, we wanted to understand the ‘value’ of ablation,” presenter Derek S. Chew, MD, MSci, research fellow at Duke Clinical Research Institute and cardiologist at the University of Calgary, Alberta, Canada, told Healio. “This is important given the ongoing debates in U.S. health care reform, where therapeutic strategies not only required that they produce significant clinical benefits, such as reduction in clinical events or improvements in quality of life, but that they are also cost-effective. In other words, we wanted to understand the relative efficiency of ablation compared to drug therapy in producing clinical benefits according to conventional societal benchmarks of good value for money in health care.”
The researchers obtained patient costs from prospectively collected medical bills from U.S. patients; used costs predicted from multivariable models for non-U.S. patients; included medication and outpatient costs; included physician costs using Medicare fee schedule mapped to case report data; and modeled events over a lifetime horizon, Chew said during a press conference. Costs were expressed in 2018 U.S. dollars. The results from the intention-to-treat analysis were used, Chew told Healio.
For the ablation group, lifetime costs were $150,987 and quality-adjusted life-years were 11.01, whereas for the medical therapy group, lifetime costs were $135,594 and QALYs were 10.74, Chew said during the press conference.
The incremental cost-effectiveness ratio (ICER) for ablation was $57,433 per QALY gained, which is below the threshold of $100,000 commonly used in the U.S., Chew said during the press conference.
In 5,000 bootstrap simulations, 75% of them had an ICER of less than $100,000 per QALY gained, he said.
“This result is attributed primarily to substantial gains in quality of life, as we did not find a meaningful reduction in health care costs to offset the cost of the initial ablation procedure, and by intention-to-treat analysis there were not significant gains in life expectancy with ablation,” Chew told Healio.
In a subgroup analysis of 778 patients from the cohort with HF (NYHA class II or worse at baseline), the ICER for catheter ablation was $54,321 per QALY gained, and in 5,000 bootstrap simulations, 85% of them had an ICER of less than $100,000 per QALY gained, according to the researchers.
Unlike with the overall cohort, “the cost-effectiveness in this subgroup was driven by both gains in life expectancy and quality of life,” Chew told Healio.
Perspective
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Daniel J. Cantillon, MD, FACC, FHRS
In the present analysis from the CABANA trial, the improvement in quality of life, AF burden and recurrence rates associated with catheter ablation over drug therapy seen in the original study were analyzed in terms of cost-effectiveness and found to have a savings of $57,433 per QALY gained overall, and $54,321 among patients with HF.
The superiority of catheter ablation over drug therapy in the treatment of AF is also associated with substantial cost savings, which makes our clinical recommendation to patients grounded on tangible benefits to them also economically attractive to the health care system at large. That’s a win-win.
Since the publication of the original CABANA trial, additional studies such as STOP AF and EARLY AF demonstrate the advantages of first-line ablation over drug therapy, and the superiority of earlier rhythm control treatment.
The economic advantages of a better upfront AF treatment shouldn’t really surprise anybody, as the costs associated with treating AF recurrences involve costly measures such as ED visits, hospitalizations, ICU transfers and additional procedures such as cardioversions, where patients are shocked back to normal rhythm.
Simply put, if you lower AF recurrence rates, the upfront expenditure of a better treatment will pay for itself over time, and then some, as this analysis shows.
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Chew DS, et al. LBCT03-03. Presented at: Heart Rhythm 2021; July 28-31, 2021 (hybrid meeting).
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