Cost-effectiveness of rhythm versus rate control in atrial fibrillation.
BACKGROUND
Atrial fibrillation is the most common type of sustained cardiac arrhythmia, but recent trials have identified no clear advantage of rhythm control over rate control. Consequently, economic factors often play a role in guiding treatment selection.


OBJECTIVE
To estimate the cost-effectiveness of rhythm-control versus rate-control strategies for atrial fibrillation in the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM).


METHODS
Retrospective economic evaluation. Nonparametric bootstrapping was used to estimate the distribution of incremental costs and effects on the cost-effectiveness plane.


METHODS
Data on survival and use of health care resources were obtained for all 4060 AFFIRM participants. Unit costs were estimated from various U.S. databases.


METHODS
Patients with atrial fibrillation who were 65 years of age or who had other risk factors for stroke or death, similar to those enrolled in AFFIRM.


METHODS
Mean follow-up of 3.5 years.


CONCLUSIONS
Third-party payer.


METHODS
Management of patients with atrial fibrillation with antiarrhythmic drugs (rhythm control) compared with drugs that control heart rate (rate control).


METHODS
Mean survival, resource use, costs, and cost-effectiveness.


RESULTS
A mean survival gain of 0.08 year (P = 0.10) was observed for rate control. Patients in the rate-control group used fewer resources (hospital days, pacemaker procedures, cardioversions, and short-stay and emergency department visits). Rate control costs 5077 dollars less per person than rhythm control.


RESULTS
Cost savings ranged from 2189 dollars o 5481 dollars per person. Rhythm control was more costly and less effective than rate control in 95% of the bootstrap replicates over a wide range of cost assumptions.


CONCLUSIONS
Resource use was limited to key items collected in AFFIRM, and the results are generalizable only to similar patient populations with atrial fibrillation.


CONCLUSIONS
Rate control is a cost-effective approach to the management of atrial fibrillation compared with maintenance of sinus rhythm in patients with atrial fibrillation similar to those enrolled in AFFIRM.
Marshall
Deborah A
DA
Center for Evaluation of Medicine, McMaster University and St. Joseph's Hospital, Hamilton, Ontario, Canada. marshd@mcmaster.ca
Levy
Adrian R
AR
Vidaillet
Humberto
H
Fenwick
Elisabeth
E
Slee
April
A
Blackhouse
Gordon
G
Greene
H Leon
HL
Wyse
D George
DG
Nichol
Graham
G
O'Brien
Bernie J
BJ
D000889:Anti-Arrhythmia Agents / Q000191:economics / Q000627:therapeutic use; D000925:Anticoagulants / Q000191:economics / Q000627:therapeutic use; D001281:Atrial Fibrillation / Q000188:drug therapy / Q000401:mortality / Q000628:therapy*; D006348:Cardiac Surgical Procedures / Q000191:economics; D017115:Catheter Ablation / Q000191:economics; D003198:Computer Simulation; D003362:Cost-Benefit Analysis; D004554:Electric Countershock / Q000191:economics; D004636:Emergency Service, Hospital / Q000191:economics; D017721:Hospital Costs; D006801:Humans; D007902:Length of Stay / Q000191:economics; D010138:Pacemaker, Artificial / Q000191:economics; D012189:Retrospective Studies; D018709:Statistics, Nonparametric
D000889:Anti-Arrhythmia Agents; D000925:Anticoagulants