Using and interpreting cost-effectiveness acceptability curves: an example using data from a trial of management strategies for atrial fibrillation.
BACKGROUND
The cost-effectiveness acceptability curve (CEAC) is a method for summarizing the uncertainty in estimates of cost-effectiveness. The CEAC, derived from the joint distribution of costs and effects, illustrates the (Bayesian) probability that the data are consistent with a true cost-effectiveness ratio falling below a specified ceiling ratio. The objective of the paper is to illustrate how to construct and interpret a CEAC.


METHODS
A retrospective cost-effectiveness analysis of the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) randomized controlled trial with 4060 patients followed for 3.5 years. The target population was patients with atrial fibrillation who were 65 years of age or had other risk factors for stroke or death similar to those enrolled in AFFIRM. The intervention involved the management of patients with atrial fibrillation with antiarrhythmic drugs (rhythm-control) compared with drugs that control heart rate (rate-control). Measurements of mean survival, mean costs and incremental cost-effectiveness were made. The uncertainty surrounding the estimates of cost-effectiveness was illustrated through a cost-effectiveness acceptability curve.


RESULTS
The base case point estimate for the difference in effects and costs between rate and rhythm-control is 0.08 years (95% CI: -0.1 years to 0.24 years) and -5,077 US dollars (95% CI: -1,100 dollars to -11,006 dollars). The CEAC shows that the decision uncertainty surrounding the adoption of rate-control strategies is less than 1.7% regardless of the maximum acceptable ceiling ratio. Thus, there is very little uncertainty surrounding the decision to adopt rate-control compared to rhythm-control for patients with atrial fibrillation from a resource point of view.


CONCLUSIONS
The CEAC is straightforward to calculate, construct and interpret. The CEAC is useful to a decision maker faced with the choice of whether or not to adopt a technology because it provides a measure of the decision uncertainty surrounding the choice.
Fenwick
Elisabeth
E
Public Health and Health Policy, University of Glasgow, Glasgow, UK. e.fenwick@clinmed.gla.ac.uk
Marshall
Deborah A
DA
Levy
Adrian R
AR
Nichol
Graham
G
D000368:Aged; D000889:Anti-Arrhythmia Agents / Q000191:economics / Q000627:therapeutic use; D000925:Anticoagulants / Q000191:economics / Q000627:therapeutic use; D001281:Atrial Fibrillation / Q000188:drug therapy / Q000191:economics / Q000401:mortality; D001499:Bayes Theorem; D002317:Cardiovascular Agents / Q000145:classification / Q000191:economics / Q000627:therapeutic use; D016001:Confidence Intervals; D003362:Cost-Benefit Analysis / Q000706:statistics & numerical data*; D006339:Heart Rate / Q000187:drug effects; D006801:Humans; D016032:Randomized Controlled Trials as Topic / Q000191:economics / Q000379:methods; D016019:Survival Analysis; D013673:Technology Assessment, Biomedical / Q000191:economics* / Q000379:methods; D016896:Treatment Outcome; D035501:Uncertainty
D000889:Anti-Arrhythmia Agents; D000925:Anticoagulants; D002317:Cardiovascular Agents