An economic evaluation of first-line cryoballoon ablation vs antiarrhythmic drug therapy for the treatment of paroxysmal atrial fibrillation from a U.S. Medicare perspective

Oussama Wazni; Joe Moss; Malte Kuniss; Jason Andrade; Gian Battista Chierchia; Stuart Mealing; Waruiru Mburu; Alicia Sale; Rachelle Kaplon; Eleni Ismyrloglou; Tom Bromilow; Emily Lane; Damian Lewis; Matthew R Reynolds

doi:10.1016/j.hroo.2023.07.007

An economic evaluation of first-line cryoballoon ablation vs antiarrhythmic drug therapy for the treatment of paroxysmal atrial fibrillation from a U.S. Medicare perspective

Heart Rhythm O2. 2023 Jul 27;4(9):528-537. doi: 10.1016/j.hroo.2023.07.007. eCollection 2023 Sep.

Authors

Affiliations

¹ Department of Cardiac Electrophysiology and Pacing, Cleveland Clinic, Cleveland, Ohio.
² York Health Economics Consortium, York, United Kingdom.
³ Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany.
⁴ Division of Cardiology and Cardiac Electrophysiology, University of British Columbia, Vancouver, British Columbia, Canada.
⁵ Department of Cardiology at Heart Rhythm Management Center, Universitair Ziekenhuis Brussel and Vrije Universiteit Brussel, Brussels, Belgium.
⁶ Medtronic, Mounds View, Minnesota.
⁷ Medtronic Bakken Research Center B.V., Maastricht, the Netherlands.
⁸ Baim Institute for Clinical Research, Boston, Massachusetts.
⁹ Lahey Hospital and Medical Center, Burlington, Massachusetts.

Abstract

Background: Three recent randomized controlled trials have demonstrated that, as an initial rhythm control strategy, first-line cryoballoon ablation (cryoablation) reduces atrial arrhythmia recurrence compared with antiarrhythmic drugs (AADs) in patients with symptomatic paroxysmal atrial fibrillation (PAF).

Objective: The study sought to evaluate the cost-effectiveness of first-line cryoablation compared with first-line AADs for treating symptomatic PAF from a U.S. Medicare payer perspective.

Methods: Individual patient-level data from 703 participants with PAF enrolled into the Cryo-FIRST (NCT01803438), STOP AF First (NCT03118518), and EARLY-AF (NCT02825979) trials were used to derive parameters for the cost-effectiveness model. The cost-effectiveness model used a hybrid decision tree and Markov structure. The decision tree had a 1-year time horizon and was used to inform the initial health state allocation in the first cycle of the Markov model. The Markov model used a 40-year time horizon (3-month cycle length). Health benefits were expressed in quality-adjusted life years (QALYs). Costs and benefits were discounted at 3% per year.

Results: Cryoablation was estimated to yield higher QALYs (+0.17) and higher costs (+$4274) per patient over a 40-year time horizon than AADs. Ultimately, this produced an average incremental cost-effectiveness ratio of $24,637 per QALY gained. Independent of initial treatment, individuals were expected to receive ∼1.2 ablations over a lifetime. There was a 45% relative reduction in time spent in atrial fibrillation health states for those initially treated with cryoablation compared with AADs.

Conclusion: Initial rhythm control with first-line cryoballoon ablation is highly cost-effective compared with first-line AADs from a U.S. Medicare payer perspective.

Keywords: Ablation; Antiarrhythmic drug; Cost-effectiveness; Cryoablation; Cryoballoon; Economic evaluation; Initial rhythm control; Paroxysmal atrial fibrillation; Pulmonary vein isolation.