Long-term cost-effectiveness of transcatheter versus surgical closure of secundum atrial septal defect in adults.
BACKGROUND
The most common congenital anomaly in adults is secundum, which can be closed using a surgical or transcatheter approach. Despite the growing use of transcatheter ASD closure, few studies have examined the cost-effectiveness of this strategy. We sought to compare the long-term cost effectiveness of transcatheter and surgical closure of secundum in adults.


METHODS
A decision-analytic model was used with all clinical outcome parameter estimates obtained from the province-wide Québec Congenital Heart Disease Database. Costs were obtained from a single academic centre (Canadian dollars). A cost-effectiveness analysis using a discrete event Monte Carlo simulation model from the perspective of a single third party payer and multiple sensitivity analyses were performed. Patients were followed for a maximum of 5 years after ASD closure.


RESULTS
Between l998 and 2005, we identified 718 adults (n=335 transcatheter; n=383 surgical) who underwent ASD closure in Quebec. The 5-year cost of surgical closure was $15,304 SD $4581 versus $11,060 SD $5169 for the transcatheter alternative. At 5 years, transcatheter closure was marginally more effective than surgery (4.683 SD 0.379 life-years versus 4.618 SD 0.638 life-years). Probabilistic sensitivity analyses demonstrated that transcatheter ASD closure was a dominant strategy with an 80% probability of cost savings and equal or greater efficacy compared to surgical treatment.


CONCLUSIONS
Although definitive conclusions are limited given the observational nature of the primary data sources, transcatheter ASD closure appeared to be a cost-effective strategy associated with slightly improved clinical outcomes and reduced costs compared to surgical closure at 5-years follow-up.
McGill Adult Unit for Congenital Heart Disease Excellence (MAUDE Unit), McGill University Health Centre, Canada.
Darren
D
Mylotte
McGill Adult Unit for Congenital Heart Disease Excellence (MAUDE Unit), McGill University Health Centre, Canada.
Stéphane P
SP
Quenneville
McGill Adult Unit for Congenital Heart Disease Excellence (MAUDE Unit), McGill University Health Centre, Canada.
Mark A
MA
Kotowycz
Technology Assessment Unit, McGill University Health Centre, Canada.
Xuanqian
X
Xie
Department of Medicine, McGill University, Canada; Department of Epidemiology & Biostatistics, McGill University, Canada.
James M
JM
Brophy
McGill Adult Unit for Congenital Heart Disease Excellence (MAUDE Unit), McGill University Health Centre, Canada.
Raluca
R
Ionescu-Ittu
McGill Adult Unit for Congenital Heart Disease Excellence (MAUDE Unit), McGill University Health Centre, Canada.
Giuseppe
G
Martucci
Division of Clinical Epidemiology, McGill University Health Centre, Canada.
Louise
L
Pilote
McGill Adult Unit for Congenital Heart Disease Excellence (MAUDE Unit), McGill University Health Centre, Canada.
Judith
J
Therrien
McGill Adult Unit for Congenital Heart Disease Excellence (MAUDE Unit), McGill University Health Centre, Canada. Electronic address: ariane.marelli@mcgill.ca.
Ariane J
AJ
Marelli
D000328:Adult; D006328:Cardiac Catheterization / Q000191:economics*; D003325:Coronary Care Units / Q000191:economics; D003362:Cost-Benefit Analysis; D016208:Databases, Factual / Q000706:statistics & numerical data; D003661:Decision Support Techniques; D005260:Female; D005500:Follow-Up Studies; D006344:Heart Septal Defects, Atrial / Q000191:economics* / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D017059:Models, Econometric; D009010:Monte Carlo Method; D011792:Quebec; D055989:Septal Occluder Device / Q000191:economics*
Adult congenital heart disease; Atrial septal defect; Cost-effectiveness; Surgery; Transcatheter