title: Cost-effectiveness of 7-day-Holter monitoring alone or in combination with transthoracic echocardiography in patients with cerebral ischemia.
abstract: OBJECTIVE
  Prolonged Holter monitoring of patients with cerebral ischemia increases the detection rate of paroxysmal atrial fibrillation (PAF); this leads to improved antithrombotic regimens aimed at preventing recurrent ischemic strokes. The aim of this study was to compare a 7-day-Holter monitoring (7-d-Holter) alone or in combination with prior selection via transthoracic echocardiography (TTE) to a standard 24-h-Holter using a cost-utility analysis.
  
  
  METHODS
  Lifetime cost, quality-adjusted life years (QALY), and incremental cost-effectiveness ratios (ICER) were estimated for a cohort of patients with acute cerebral ischemia and no contraindication to oral anticoagulation. A Markov model was developed to simulate the long-term course and progression of cerebral ischemia considering the different diagnostic algorithms (24-h-Holter, 7-d-Holter, 7-d-Holter after preselection by TTE). Clinical data for these algorithms were derived from the prospective observational Find-AF study (ISRCTN 46104198).
  
  
  RESULTS
  Predicted lifelong discounted costs were 33,837 <euro> for patients diagnosed by the 7-d-Holter and 33,852 <euro> by the standard 24-h-Holter. Cumulated QALYs were 3.868 for the 7-d-Holter compared to 3.844 for the 24-h-Holter. The 7-d-Holter dominated the 24-h-Holter in the base-case scenario and remained cost-effective in extensive sensitivity analysis of key input parameter with a maximum of 8,354 <euro>/QALY gained. Preselecting patients for the 7-d-Holter had no positive effect on the cost-effectiveness.
  
  
  CONCLUSIONS
  A 7-d-Holter to detect PAF in patients with cerebral ischemia is cost-effective. It increases the detection which leads to improved antithrombotic regimens; therefore, it avoids recurrent strokes, saves future costs, and decreases quality of life impairment. Preselecting patients by TTE does not improve cost-effectiveness.
authors.affiliation: Institute for Health Care Management and Research, University of Duisburg-Essen, Campus Essen, Schützenbahn 70, 45127, Essen, Germany, fel_mayer@web.de.
authors.forename: Felix
authors.initials: F
authors.lastname: Mayer
authors.forename: Raoul
authors.initials: R
authors.lastname: Stahrenberg
authors.forename: Klaus
authors.initials: K
authors.lastname: Gröschel
authors.forename: Sarah
authors.initials: S
authors.lastname: Mostardt
authors.forename: Janine
authors.initials: J
authors.lastname: Biermann
authors.forename: Frank
authors.initials: F
authors.lastname: Edelmann
authors.forename: Jan
authors.initials: J
authors.lastname: Liman
authors.forename: Jürgen
authors.initials: J
authors.lastname: Wasem
authors.forename: Alexander
authors.initials: A
authors.lastname: Goehler
authors.forename: Rolf
authors.initials: R
authors.lastname: Wachter
authors.forename: Anja
authors.initials: A
authors.lastname: Neumann
mesh_terms: D000368:Aged; D000465:Algorithms; D000925:Anticoagulants / Q000627:therapeutic use; D001281:Atrial Fibrillation / Q000150:complications / Q000175:diagnosis* / Q000188:drug therapy; D002545:Brain Ischemia / Q000191:economics / Q000209:etiology / Q000517:prevention & control*; D003362:Cost-Benefit Analysis; D018450:Disease Progression; D004452:Echocardiography / Q000379:methods; D015716:Electrocardiography, Ambulatory / Q000191:economics / Q000379:methods*; D006801:Humans; D008390:Markov Chains; D018579:Patient Selection; D019057:Quality-Adjusted Life Years; D055502:Secondary Prevention; D020521:Stroke / Q000191:economics / Q000209:etiology / Q000517:prevention & control*; D013997:Time Factors
chemical_list: D000925:Anticoagulants
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