title: Feasibility and cost-effectiveness of stroke prevention through community screening for atrial fibrillation using iPhone ECG in pharmacies. The SEARCH-AF study.
abstract: Atrial fibrillation (AF) causes a third of all strokes, but often goes undetected before stroke. Identification of unknown AF in the community and subsequent anti-thrombotic treatment could reduce stroke burden. We investigated community screening for unknown AF using an iPhone electrocardiogram (iECG) in pharmacies, and determined the cost-effectiveness of this strategy.Pharmacists performedpulse palpation and iECG recordings, with cardiologist iECG over-reading. General practitioner review/12-lead ECG was facilitated for suspected new AF. An automated AF algorithm was retrospectively applied to collected iECGs. Cost-effectiveness analysis incorporated costs of iECG screening, and treatment/outcome data from a United Kingdom cohort of 5,555 patients with incidentally detected asymptomatic AF. A total of 1,000 pharmacy customers aged ≥65 years (mean 76 ± 7 years; 44% male) were screened. Newly identified AF was found in 1.5% (95% CI, 0.8-2.5%); mean age 79 ± 6 years; all had CHA2DS2-VASc score ≥2. AF prevalence was 6.7% (67/1,000). The automated iECG algorithm showed 98.5% (CI, 92-100%) sensitivity for AF detection and 91.4% (CI, 89-93%) specificity. The incremental cost-effectiveness ratio of extending iECG screening into the community, based on 55% warfarin prescription adherence, would be $AUD5,988 (€3,142; $USD4,066) per Quality Adjusted Life Year gained and $AUD30,481 (€15,993; $USD20,695) for preventing one stroke. Sensitivity analysis indicated cost-effectiveness improved with increased treatment adherence.Screening with iECG in pharmacies with an automated algorithm is both feasible and cost-effective. The high and largely preventable stroke/thromboembolism risk of those with newly identified AF highlights the likely benefits of community AF screening. Guideline recommendation of community iECG AF screening should be considered.
authors.forename: Nicole
authors.initials: N
authors.lastname: Lowres
authors.forename: Lis
authors.initials: L
authors.lastname: Neubeck
authors.forename: Glenn
authors.initials: G
authors.lastname: Salkeld
authors.forename: Ines
authors.initials: I
authors.lastname: Krass
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: McLachlan
authors.forename: Julie
authors.initials: J
authors.lastname: Redfern
authors.forename: Alexandra A
authors.initials: AA
authors.lastname: Bennett
authors.forename: Tom
authors.initials: T
authors.lastname: Briffa
authors.forename: Adrian
authors.initials: A
authors.lastname: Bauman
authors.forename: Carlos
authors.initials: C
authors.lastname: Martinez
authors.forename: Christopher
authors.initials: C
authors.lastname: Wallenhorst
authors.forename: Jerrett K
authors.initials: JK
authors.lastname: Lau
authors.forename: David B
authors.initials: DB
authors.lastname: Brieger
authors.forename: Raymond W
authors.initials: RW
authors.lastname: Sy
authors.affiliation: S. Ben Freedman, Cardiology Department, Level 3, Concord Repatriation General Hospital, Hospital Road, Concord NSW 2137, Australia, Tel.: +612 9767 7358, Fax: +612 9767 6780, E-mail: ben.freedman@sydney.edu.au.
authors.forename: S Ben
authors.initials: SB
authors.lastname: Freedman
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D001281:Atrial Fibrillation / Q000175:diagnosis* / Q000453:epidemiology; D040421:Cell Phone; D003153:Community Health Services; D003362:Cost-Benefit Analysis; D003430:Cross-Sectional Studies; D003936:Diagnosis, Computer-Assisted / Q000191:economics / Q000379:methods*; D004562:Electrocardiography / Q000295:instrumentation / Q000379:methods* / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D008297:Male; D008403:Mass Screening / Q000191:economics / Q000379:methods; D009517:New South Wales / Q000453:epidemiology; D010594:Pharmacies; D010595:Pharmacists; D015995:Prevalence; D019057:Quality-Adjusted Life Years; D020521:Stroke / Q000191:economics / Q000517:prevention & control*
keywords: Atrial fibrillation; anticoagulation; cost-effectiveness; screening; stroke prevention