Cost-effectiveness analysis of radiofrequency ablation versus drugs for the treatment of a trial fibrillation in the South African population

Henry-Lines, Heather (2021-03)

Thesis (PhD)--Stellenbosch University, 2021.

Thesis

ENGLISH SUMMARY : Atrial fibrillation is the most commonly found and sustained arrhythmia. It affects about 1% of the total population and is found in more than one in ten in the elderly. The prevalence is increasing with the aging population. Patients with atrial fibrillation are at an increased risk of heart failure and all-cause mortality, and have a fivefold increased risk of stroke. Atrial fibrillation is associated with debilitating symptoms and an impaired quality of life. The restoration and maintenance of sinus rhythm is favourable and the current guidelines recommend the use of both rate and rhythm control strategies, which involve the prescription of anti-arrhythmic drug therapy. These anti-arrhythmic drugs are frequently ineffective, with large studies showing that atrial fibrillation returns in as many as 85% of patients within one year. These drugs are also associated with adverse events, occasionally serious, which may lead to hospitalisation. Catheter ablation (a minimally invasive procedure), has over the past decade revolutionised the treatment of atrial fibrillation. The 2010 European Society of Cardiology guidelines recommend catheter ablation for paroxysmal atrial fibrillation as a class IIa recommendation with level of evidence “A”. Current literature indicates that patients with atrial fibrillation who undergo pulmonary vein ablation have a significantly lower risk of death, stroke and dementia compared to patients with atrial fibrillation who are not treated with ablation, while stroke and dementia is similar to that of the general population. This study used a decision tree analysis, a Markov model and Monte Carlo simulation to calculate the cost-effectiveness of catheter ablation versus commonly used anti-arrhythmic drugs for the treatment of paroxysmal atrial fibrillation. Input into the model was founded on an extensive literature review, interviews with local electrophysiologists and a sample of real patient data, which examined the costs associated with among others, the length of hospital stay and the cost of the procedure. The model simulated 1 000 patients receiving either pulmonary vein isolation through radiofrequency ablation or anti-arrhythmic drugs and the following variables were measured, QALYs, average cost, incremental costs, average effectiveness, incremental effectiveness, average length of stay in hospital for complications, relative risk of death for radiofrequency catheter ablation versus anti-arrhythmic drugs and also the net monetary benefits. A total of fourteen variables were tested and sensitivity analyses were performed on each. It was found that in all but two cases, pulmonary vein isolation with radiofrequency catheter ablation dominated over anti-arrhythmic drug therapy as being more cost-effective for the management of paroxysmal atrial fibrillation. Finally, it was determined that pulmonary vein isolation with radiofrequency catheter ablation should be considered as a first line therapy for patients with paroxysmal atrial fibrillation in South Africa.

AFRIKAANSE OPSOMMING : Atriale fibrillasie is die mees algemene en volgehoue aritmie. Dit raak ongeveer 1% van die bevolking. Onder bejaardes is die voorkoms egter soveel as 10%, wat beteken dat die toestand toeneem in verhouding met die verouderende bevolking. Atriale fibrillasie verhoog ’n pasiënt se risiko vir beroerte vyfvoudig, tesame met hartversaking en alle-oorsake mortaliteit. Die toestand se uitmergelende simptome verlaag ook lewenskwaliteit. Die kanse vir die herstel en instandhouding van sinusritme is positief. Bestaande riglyne beveel dus die gebruik van ritme- of spoed-beheer medikasie aan, wat beteken dat anti-aritmie medikasie voorgeskryf word. Dit is egter dikwels oneffektief en verskeie omvattende studies het bewys dat tot 85% van die pasiënte binne een jaar weer ‘n ritmestoornis ervaar. Hierdie middels word ook dikwels verbind met newe-effekte wat ernstig mag wees en tot hospitalisasie mag lei. Kateterablasie (’n minimaal-ingrypende prosedure) het oor die afgelope dekade die behandeling van atriale fibrillasie onherkenbaar verander. Vir pasiënte wat hoogs simptomaties, of paroksismaal, is ten spyte van optimale terapie, beveel die Europese Vereniging van Kardiologie se 2010 riglyne ablasie aan as ‘n klas IIa aanbeveling. Huidige literatuur dui op ‘n laer koers van sterftes, beroerte en demensie onder atriale fibrillasie pasiënte wat atriale fibrillasie ablasie ondergaan, in vergelyking met pasiënte wat met medikasie behandel word. Eersgenoemde het inteendeel dieselfde risikoprofiel as die algemene bevolking. Hierdie studie gebruik ’n keuse-boom analisemodel en ’n waarskynlikheid-Markov model met Monte Carlo-simulasie om die koste-effektiwiteit van kateterablasie met anti-aritmiese medikasie te vergelyk in die behandeling van pasiënte met paroksismale atriale fibrillasie. Die data wat in die model gebruik word, is gebaseer op ’n uitgebreide literatuurstudie, onderhoude met elektrofisioloë, en ’n steekproef van pasiëntdata, en ondersoek, onder andere, die duur van hopitaalverblyf en die koste verbonde aan die prosedure. Die studie maak gebruik van ’n simulasiemodel waar 1 000 pasiënte óf ablasie óf medikasie ontvang het. Die volgende veranderlikes is gemeet: QALYs, gemiddelde koste, toenemende koste, gemiddelde doeltreffendheid, toenemende doeltreffendheid, gemiddelde hospitaalverblyf tydens komplikasies, die relatiewe riskio van sterfte en monetêre voordele. Veertien veranderlikes is getoets en aan sensitiwiteitsanalises onderwerp. In dertien uit die viertien analises was kateterablasie meer koste-effektief as anti-aritmiese medikasie in die behandeling en bestuur van anti-aritmiese medikasie. Die studie kom dus tot die gevolgtrekking dat kateterablasie oorweeg moet word as voorkeurterapie vir pasiënte met paroksismale atriale fibrillasie in Suid-Afrika.

Please refer to this item in SUNScholar by using the following persistent URL: http://hdl.handle.net/10019.1/109974
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