title: Cost-effectiveness of transesophageal echocardiographic-guided cardioversion: a decision analytic model for patients admitted to the hospital with atrial fibrillation.
abstract: OBJECTIVE
  Using a decision-analytic model, we sought to examine the cost-effectiveness of three strategies for cardioversion of patients admitted to the hospital with atrial fibrillation.
  
  
  BACKGROUND
  Transesophageal echocardiographic (TEE)-guided cardioversion has been proposed as a method for early cardioversion of patients with atrial fibrillation. The cost-effectiveness of this approach, relative to conventional therapy, has not been studied.
  
  
  METHODS
  We ascertained the cost per quality-adjusted life-year (QALY) of three strategies: 1) conventional therapy--transthoracic echocardiography (TTE) and warfarin therapy for 1 month before cardioversion; 2) initial TTE, followed by TEE and early cardioversion if no thrombus is detected; 3) initial TEE, with early cardioversion if no thrombus is detected. With strategies 2 and 3, if a thrombus is seen, follow-up TEE is performed. If no thrombus is seen, cardioversion is then performed. All strategies utilized anticoagulation before and extending for 1 month after cardioversion. Life expectancy, utilities (quality-of-life weights) and event probabilities were ascertained from published reports. Cost estimates were based on published data and hospital accounting information.
  
  
  RESULTS
  Transesophageal echocardiographic-guided early cardioversion (strategy 3: cost $2,774, QALY 8.49) dominates TTE/TEE-guided cardioversion (strategy 2: cost $3,106, QALY 8.48) and conventional therapy (strategy 1: cost $3,070, QALY 8.48) because it is the least costly with similar effectiveness. Sensitivity analyses demonstrated that TEE-guided cardioversion (strategy 3) dominates conventional therapy if the risk of stroke after TEE negative for atrial thrombus is slightly less than that after conventional therapy (baseline estimate 0.8%). The results also depend on the risk of major hemorrhage but are less sensitive to baseline estimates of morbidity from TEE, cost of TTE, cost of hospital admission for cardioversion and utilities for health states.
  
  
  CONCLUSIONS
  On the basis of a decision-analytic model, TEE-guided early cardioversion, without TTE, is a reasonable cost-saving alternative to conventional therapy for patients admitted to the hospital with atrial fibrillation. Such a strategy appears particularly beneficial for patients with an increased risk of hemorrhagic complications. Future clinical studies examining the TEE strategy should consider eliminating initial TTE and carefully assess both the thromboembolic and hemorrhagic risk.
authors.affiliation: Charles A. Dana Research Institute, Boston, Massachusetts, USA.
authors.forename: T B
authors.initials: TB
authors.lastname: Seto
authors.forename: D A
authors.initials: DA
authors.lastname: Taira
authors.forename: J
authors.initials: J
authors.lastname: Tsevat
authors.forename: W J
authors.initials: WJ
authors.lastname: Manning
mesh_terms: D000368:Aged; D000925:Anticoagulants / Q000627:therapeutic use; D001281:Atrial Fibrillation / Q000191:economics* / Q000628:therapy*; D002561:Cerebrovascular Disorders / Q000453:epidemiology / Q000517:prevention & control; D003362:Cost-Benefit Analysis; D003365:Costs and Cost Analysis; D003661:Decision Support Techniques; D004452:Echocardiography / Q000191:economics; D017548:Echocardiography, Transesophageal / Q000191:economics; D004554:Electric Countershock / Q000191:economics* / Q000379:methods; D005260:Female; D006331:Heart Diseases / Q000000981:diagnostic imaging; D006470:Hemorrhage / Q000139:chemically induced / Q000453:epidemiology; D006801:Humans; D008297:Male; D019057:Quality-Adjusted Life Years; D012307:Risk Factors; D012680:Sensitivity and Specificity; D013927:Thrombosis / Q000000981:diagnostic imaging; D013997:Time Factors; D014859:Warfarin / Q000627:therapeutic use
chemical_list: D000925:Anticoagulants; D014859:Warfarin