Real-World Cost-Effectiveness of Pulmonary Vein Isolation for Atrial Fibrillation: A Target Trial Approach

Miquel Serra-Burriel; Helena Aebersold; Fabienne Foster-Witassek; Michael Coslovsky; Nicolas Rodondi; Manuel R Blum; Christian Sticherling; Giorgio Moschovitis; Jürg H Beer; Tobias Reichlin; Philipp Krisai; Stefanie Aeschbacher; Rebecca E Paladini; Michael Kühne; Stefan Osswald; David Conen; Stefan Felder; Matthias Schwenkglenks; Swiss-AF investigators

doi:10.1016/j.jval.2023.08.008

Real-World Cost-Effectiveness of Pulmonary Vein Isolation for Atrial Fibrillation: A Target Trial Approach

Value Health. 2023 Dec;26(12):1721-1729. doi: 10.1016/j.jval.2023.08.008. Epub 2023 Sep 22.

Authors

Miquel Serra-Burriel¹, Helena Aebersold², Fabienne Foster-Witassek², Michael Coslovsky³, Nicolas Rodondi⁴, Manuel R Blum⁴, Christian Sticherling⁵, Giorgio Moschovitis⁶, Jürg H Beer⁷, Tobias Reichlin⁸, Philipp Krisai⁵, Stefanie Aeschbacher⁵, Rebecca E Paladini⁵, Michael Kühne⁵, Stefan Osswald⁵, David Conen⁹, Stefan Felder¹⁰, Matthias Schwenkglenks¹¹; Swiss-AF investigators

Affiliations

¹ Epidemiology, Biostatistics, and Prevention Institute, University of Zurich, Zurich, Switzerland. Electronic address: miquel.serraburriel@uzh.ch.
² Epidemiology, Biostatistics, and Prevention Institute, University of Zurich, Zurich, Switzerland.
³ Department of Clinical Research, University of Basel, University Hospital, Basel, Switzerland; Cardiovascular Research Institute Basel, University of Basel, University Hospital, Basel, Switzerland.
⁴ Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland.
⁵ Cardiovascular Research Institute Basel, University of Basel, University Hospital, Basel, Switzerland; Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; Department of Medicine, University Hospital Basel, University of Basel, Basel, Switzerland.
⁶ Division of Cardiology, Ente Ospedaliero Cantonale, Regional Hospital of Lugano, Lugano, Switzerland.
⁷ Department of Medicine, Cantonal Hospital of Baden and Molecular Cardiology, University Hospital of Zürich, Zurich, Switzerland.
⁸ Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
⁹ Population Health Research Institute, McMaster University, Hamilton, Canada.
¹⁰ Department of Business and Economics, University of Basel, Basel, Switzerland.
¹¹ Epidemiology, Biostatistics, and Prevention Institute, University of Zurich, Zurich, Switzerland; Health Economics Facility, Department of Public Health, University of Basel, Basel, Switzerland.

PMID: 37741443
DOI: 10.1016/j.jval.2023.08.008

Abstract

Objectives: Randomized controlled trials of pulmonary vein isolation (PVI) for treating atrial fibrillation (AF) have proven the procedure's efficacy. Studies assessing its empirical cost-effectiveness outside randomized trial settings are lacking. We aimed to evaluate the effectiveness and cost-effectiveness of PVI versus medical therapy for AF.

Methods: We followed a target trial approach using the Swiss-AF cohort, a prospective observational cohort study that enrolled patients with AF between 2014 and 2017. Resource utilization and cost information were collected through claims data. Quality of life was measured with EQ-5D-3L utilities. We estimated incremental cost-effectiveness ratios (ICERs) from the perspective of the Swiss statutory health insurance system.

Results: Patients undergoing PVI compared with medical therapy had a 5-year overall survival advantage with a hazard ratio of 0.75 (95% CI 0.46-1.21; P = .69) and a 19.8% SD improvement in quality of life (95% CI 15.5-22.9; P < .001), at an incremental cost of 29 604 Swiss francs (CHF) (95% CI 16 354-42 855; P < .001). The estimated ICER was CHF 158 612 per quality-adjusted life-year (QALY) gained within a 5-year time horizon. Assuming similar health effects and costs over 5 additional years changed the ICER to CHF 82 195 per QALY gained. Results were robust to the sensitivity analyses performed.

Conclusions: Our results show that PVI might be a cost-effective intervention within the Swiss healthcare context in a 10-year time horizon, but unlikely to be so at 5 years, if a willingness-to-pay threshold of CHF 100 000 per QALY gained is assumed. Given data availability, we find target trial designs are a valuable tool for assessing the cost-effectiveness of healthcare interventions outside of randomized controlled trial settings.

Keywords: atrial fibrillation; causal inference; cost-effectiveness; pulmonary vein isolation; target trial.

Publication types

Observational Study

MeSH terms

Atrial Fibrillation* / surgery
Cost-Benefit Analysis
Humans
Prospective Studies
Pulmonary Veins* / surgery
Quality of Life
Quality-Adjusted Life Years