AF screening may lower cost, increase QALYs in older adults
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Atrial fibrillation screening in older patients in Sweden was associated with lower cost after 3 years and a gain in quality-adjusted life-years compared with not screening, according to data published in the European Heart Journal.
“This is the first health-economic study using actual long-term clinical follow-up data from a randomized trial in screening for AF. Using within-trial data with a median follow-up time of 6.9 years ... the main results showed that screening for AF was associated with both lower costs and gained QALYs,” Johan Lyth, MD, PhD, associate professor in the department of health, medicine and caring sciences at Linköping University, Sweden, and colleagues wrote. “The screening strategy was thus dominant vs. non-screening and cost-saving, after 3 years. This was mainly explained by a low cost for screening and oral anticoagulant treatment, in addition to fewer cases of stroke in the screening invitation group.”
For the STROKESTOP study, adults aged 75 and 76 years in Sweden were enrolled into a population-based AF screening program. A total of 7,165 participants were randomly assigned to AF screening while 13,996 were assigned to no screening. The cohort was followed for a median of 6.9 years. A total of 3% of the screening arm had previously undetected AF detected during the study period; 0.5% had new AF detected; and 3.7% of the screened population initiated oral anticoagulation.
The results of the STROKESTOP trial, including data on the prevalence of AF, oral anticoagulant use, clinical event data and all-cause mortality were utilized by Lyth and colleagues to estimate the cost-effectiveness of population-based AF screening in Sweden.
Researchers reported that for every 1,000 people screened, the population gained approximately 77 life-years and 65 QALYs.
Among participants assigned to AF screening, the incremental cost was approximately 1.77 million euros lower at 3 years compared with those not screened. This finding combined with the gained QALYs led researchers to determine that the AF screening strategy was dominant.
Following 10,000 Monte Carlo simulations, researchers observed that the AF screening strategy was cost-effective in 99.2% and cost-saving in 92.7% of the simulations.
Moreover, screening of 1,000 individuals resulted in 10.6 fewer strokes (95% CI, 22.5 to 1.4), one more case of systemic embolism (95% CI, 1.9 to 4.1) and 2.9 fewer bleeds requiring hospitalization (95% CI, 18.2 to 13.1).
“This study is based on the Swedish cost structure and cost levels,” the researchers wrote. “Since health care systems and cost levels vary for different countries, the results could therefore not be directly applied in other health care systems.”
Reference:
Perspective
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This study adds to the growing evidence demonstrating the cost-effectiveness of AF screening and is distinct from prior economic analyses because it is based on actual long-term study data with fewer assumptions.
More research is needed to determine whether AF screening in other countries with different health care systems and cost structures.
The STROKESTOP study has demonstrated what is possible when systematic AF screening is performed under ideal circumstances. Compared to the single-payer health care system in Sweden with universal access for all citizens, the U.S. health care system is more complex with respect to insurance, access and care delivery, all of which need careful consideration before implementing a broad AF screening program.
One of the main reasons why the U.S. Preventive Services Task Force concluded there is not enough evidence to recommend either for or against AF screening was due to the lack of data regarding the benefits and harms of anticoagulation therapy among screen-detected AF patients. They did not specifically consider cost-effectiveness however, in order to implement a screening program demonstrating the cost of case-finding (diagnosis and treatment) is economically balanced in relation to possible expenditure on the health system as a whole is needed.
There are several key factors involved in performing an economic evaluation for an AF screening program including the participation rate in screening program; rate of undiagnosed AF in a targeted population; difference in AF detection between screening and usual care; stroke risk in a targeted population; stroke risk reduction and increase in bleeding risk from oral anticoagulation therapy; and acceptable threshold for willingness to pay, for example $50,000 per QALY or 20,000 to 30,000 U.K. pounds per QALY.
Associate Professor of Cardiology
Smidt Heart Institute, Cedars-Sinai
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