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Arrhythmias and sudden death
Original research article
Cost-effectiveness of an insertable cardiac monitor in a high-risk population in the UK
  1. Claudia I Rinciog1,
  2. Laura M Sawyer1,
  3. Alexander Diamantopoulos1,
  4. Mitchell S V Elkind2,
  5. Matthew Reynolds3,
  6. Stylianos I Tsintzos4,
  7. Paul D Ziegler5,
  8. Maria E Quiroz5,
  9. Claudia Wolff4 and
  10. Klaus K Witte6
  1. 1Symmetron Limited, London, UK
  2. 2Neurology Department, Columbia University College of Physicians and Surgeons, New York, New York, USA
  3. 3Cardiovascular Medicine, Baim Institute for Clinical Research, Boston, Massachusetts, USA
  4. 4Health Economics and Reimbursement, Medtronic International Trading Sarl, Tolochenaz, Switzerland
  5. 5Cardiac Rhythm and Heart Failure, Medtronic, Mounds View, Minnesota, USA
  6. 6Division of Cardiovascular and Diabetes Research, University of Leeds, Leeds, UK
  1. Correspondence to Claudia I Rinciog; crinciog{at}symmetron.net

Abstract

Objective To evaluate the cost-effectiveness of insertable cardiac monitors (ICMs) compared with standard of care (SoC) for detecting atrial fibrillation (AF) in patients at high risk of stroke (CHADS2 >2), using a UK National Health Service (NHS) perspective.

Methods Using patient characteristics and clinical data from the REVEAL AF trial, a Markov model assessed the cost-effectiveness of detecting AF with an ICM compared with SoC. Costs and benefits were extrapolated across modelled patient lifetime. Ischaemic and haemorrhagic strokes, intracranial and extracranial haemorrhages and minor bleeds were modelled. Diagnostic and device costs were included, plus costs of treating stroke and bleeding events and costs of oral anticoagulants (OACs). Costs and health outcomes, measured as quality-adjusted life years (QALYs), were discounted at 3.5% per annum. One-way deterministic and probabilistic sensitivity analyses (PSA) were undertaken.

Results The total per-patient cost for ICM was £13 360 versus £11 936 for SoC (namely, annual 24 hours Holter monitoring). ICMs generated a total of 6.50 QALYs versus 6.30 for SoC. The incremental cost-effectiveness ratio (ICER) was £7140/QALY gained, below the £20 000/QALY acceptability threshold. ICMs were cost-effective in 77.4% of PSA simulations. The number of ICMs needed to prevent one stroke was 21 and to cause a major bleed was 37. ICERs were sensitive to assumed proportions of patients initiating or discontinuing OAC after AF diagnosis, type of OAC used and how intense the traditional monitoring was assumed to be under SoC.

Conclusions The use of ICMs to identify AF in a high-risk population is cost-effective for the UK NHS.

  • atrial fibrillation
  • insertable cardiac monitor
  • cost-effectiveness analysis
  • economics
  • oral anticoagulation therapy

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/openhrt-2019-001037

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    Footnotes

    • Contributors CR, LS, AD, MQ and ST conceived the analysis. CR and LS conducted the analysis. PZ, ME, MR and KW validated the model structure, assumptions and inputs. CR and LS wrote the introduction, methods and results. ST, CR and LS wrote the discussion section. All authors provided critical feedback on the manuscript and have approved the final version.

    • Funding REVEAL AF and this cost-effectiveness analysis were funded by Medtronic plc.

    • Competing interests CR, LS and AD are employed by Symmetron Ltd, which received funding from Medtronic plc for this analysis. ME’s institution has received payments from Medtronic plc for ME’s participation in this analysis. KW and MR have received consultancy fees from Medtronic plc. ST, PZ and CW are employees and have equity interest in Medtronic plc. MQ was a Medtronic employee at the time of the analysis.

    • Patient consent for publication Not required.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information.