title: Identifying future research priorities using value of information analyses: left atrial appendage occlusion devices in atrial fibrillation.
abstract: BACKGROUND
  Left atrial appendage occlusion devices are cost effective for stroke prophylaxis in atrial fibrillation when compared with dabigatran or warfarin. We illustrate the use of value-of-information analyses to quantify the degree and consequences of decisional uncertainty and to identify future research priorities.
  
  
  RESULTS
  A microsimulation decision-analytic model compared left atrial appendage occlusion devices to dabigatran or warfarin in atrial fibrillation. Probabilistic sensitivity analysis quantified the degree of parameter uncertainty. Expected value of perfect information analyses showed the consequences of this uncertainty. Expected value of partial perfect information analyses were done on sets of input parameters (cost, utilities, and probabilities) to identify the source of the greatest uncertainty. One-way sensitivity analyses identified individual parameters for expected value of partial perfect information analyses. Population expected value of perfect information and expected value of partial perfect information provided an upper bound on the cost of future research. Substantial uncertainty was identified, with left atrial appendage occlusion devices being preferred in only 47% of simulations. The expected value of perfect information was $8542 per patient and $227.3 million at a population level. The expected value of partial perfect information for the set of probability parameters represented the most important source of uncertainty, at $6875. Identified in 1-way sensitivity analyses, the expected value of partial perfect information for the odds ratio for stroke with left atrial appendage occlusion compared with warfarin was calculated at $7312 per patient or $194.5 million at a population level.
  
  
  CONCLUSIONS
  The relative efficacy of stroke reduction with left atrial appendage occlusion devices in relation to warfarin is an important source of uncertainty. Improving estimates of this parameter should be the priority for future research in this area.
authors.affiliation: Faculty of Medicine, University of Ottawa, Ontario, Canada (A.M.).
authors.forename: Andrew
authors.initials: A
authors.lastname: Micieli
authors.affiliation: Division of Cardiology, Schulich Heart Centre and Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada (M.C.B., S.M.S., H.C.W.).
authors.forename: Maria C
authors.initials: MC
authors.lastname: Bennell
authors.affiliation: Toronto Health Economics and Technology Assessment Collaborative, Toronto, Ontario, Canada (B.P., M.K., H.C.W.).
authors.forename: Ba'
authors.initials: B
authors.lastname: Pham
authors.affiliation: Institute of Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada (M.K., H.C.W.) Faculty of Pharmacy, University of Toronto, Ontario, Canada (M.K.) Toronto Health Economics and Technology Assessment Collaborative, Toronto, Ontario, Canada (B.P., M.K., H.C.W.) Institute for Clinical Evaluative Sciences (ICES), TorontoOntario, Canada (M.K., H.C.W.).
authors.forename: Murray
authors.initials: M
authors.lastname: Krahn
authors.affiliation: Division of Cardiology, Schulich Heart Centre and Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada (M.C.B., S.M.S., H.C.W.).
authors.forename: Sheldon M
authors.initials: SM
authors.lastname: Singh
authors.affiliation: Division of Cardiology, Schulich Heart Centre and Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada (M.C.B., S.M.S., H.C.W.) Institute of Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada (M.K., H.C.W.) Toronto Health Economics and Technology Assessment Collaborative, Toronto, Ontario, Canada (B.P., M.K., H.C.W.) Institute for Clinical Evaluative Sciences (ICES), TorontoOntario, Canada (M.K., H.C.W.) Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada (H.C.W.).
authors.forename: Harindra C
authors.initials: HC
authors.lastname: Wijeysundera
mesh_terms: D000368:Aged; D000925:Anticoagulants / Q000191:economics / Q000627:therapeutic use*; D020517:Atrial Appendage / Q000503:physiopathology / Q000601:surgery*; D001281:Atrial Fibrillation / Q000150:complications / Q000191:economics / Q000503:physiopathology / Q000601:surgery*; D001562:Benzimidazoles / Q000191:economics / Q000627:therapeutic use*; D006348:Cardiac Surgical Procedures / Q000295:instrumentation*; D057186:Comparative Effectiveness Research; D003198:Computer Simulation; D003362:Cost-Benefit Analysis; D000069604:Dabigatran; D003661:Decision Support Techniques; D016527:Drug Costs; D004867:Equipment Design; D005260:Female; D017048:Health Care Costs; D006801:Humans; D008297:Male; D008390:Markov Chains; D018803:Models, Economic; D015233:Models, Statistical; D011336:Probability; D019057:Quality-Adjusted Life Years; D020521:Stroke / Q000191:economics / Q000209:etiology / Q000517:prevention & control*; D016896:Treatment Outcome; D035501:Uncertainty; D014859:Warfarin / Q000191:economics / Q000627:therapeutic use*; D015091:beta-Alanine / Q000031:analogs & derivatives* / Q000191:economics / Q000627:therapeutic use
chemical_list: D000925:Anticoagulants; D001562:Benzimidazoles; D015091:beta-Alanine; D014859:Warfarin; D000069604:Dabigatran
keywords: anticoagulants; atrial appendage occluders; atrial fibrillation; value of information