title: Cost-effectiveness of an insertable cardiac monitor to detect atrial fibrillation in patients with cryptogenic stroke.
abstract: OBJECTIVE
  Documentation of atrial fibrillation is required to initiate oral anticoagulation therapy for recurrent stroke prevention. Atrial fibrillation often goes undetected with traditional electrocardiogram monitoring techniques. We evaluated whether atrial fibrillation detection using continuous long-term monitoring with an insertable cardiac monitor is cost-effective for preventing recurrent stroke in patients with cryptogenic stroke, in comparison to the standard of care.
  
  
  METHODS
  A lifetime Markov model was developed to estimate the cost-effectiveness of insertable cardiac monitors from a UK National Health Service perspective using data from the randomized CRYSTAL-AF trial and other published literature. We also conducted scenario analyses (CHADS2 score) and probabilistic sensitivity analyses. All costs and benefits were discounted at 3.5%.
  
  
  RESULTS
  Monitoring cryptogenic stroke patients with an insertable cardiac monitor was associated with fewer recurrent strokes and increased quality-adjusted life years compared to the standard of care (7.37 vs 7.22). Stroke-related costs were reduced in insertable cardiac monitor patients, but overall costs remained higher than the standard of care (£19,631 vs £17,045). The incremental cost-effectiveness ratio was £17,175 per quality-adjusted life years gained, compared to standard of care in the base-case scenario, which is below established quality-adjusted life years willingness-to-pay thresholds. When warfarin replaced non-vitamin-K oral anticoagulants as the main anticoagulation therapy, the incremental cost-effectiveness ratio was £13,296 per quality-adjusted life years gained.
  
  
  CONCLUSIONS
  Insertable cardiac monitors are a cost-effective diagnostic tool for the prevention of recurrent stroke in patients with cryptogenic stroke. The cost-effectiveness results have relevance for the UK and across value-based healthcare systems that assess costs relative to outcomes.
authors.affiliation: Symmetron Limited, Kinetic Centre, Elstree, London, UK.
authors.forename: Alex
authors.initials: A
authors.lastname: Diamantopoulos
authors.affiliation: Symmetron Limited, Kinetic Centre, Elstree, London, UK.
authors.forename: Laura M
authors.initials: LM
authors.lastname: Sawyer
authors.affiliation: University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham, UK Department of Clinical Medicine, Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark Lahey Hospital & Medical Center, Burlington, MA, USA.
authors.forename: Gregory Y H
authors.initials: GY
authors.lastname: Lip
authors.affiliation: Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK.
authors.forename: Klaus K
authors.initials: KK
authors.lastname: Witte
authors.affiliation: Economics and Quality of Life Research, Harvard Clinical Research Institute, Boston, MA, USA.
authors.forename: Matthew R
authors.initials: MR
authors.lastname: Reynolds
authors.affiliation: Service de Cardiologie, Centre Hospitalier Universitaire Trousseau et Faculté de Médecine, Université François Rabelais, Tours, France.
authors.forename: Laurent
authors.initials: L
authors.lastname: Fauchier
authors.affiliation: Department of Neurology, Austin Health and Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, Australia.
authors.forename: Vincent
authors.initials: V
authors.lastname: Thijs
authors.affiliation: Medtronic, Tolochenaz, Switzerland.
authors.forename: Ben
authors.initials: B
authors.lastname: Brown
authors.affiliation: Medtronic, Mounds View, MN, USA.
authors.forename: Maria E
authors.initials: ME
authors.lastname: Quiroz Angulo
authors.affiliation: Department of Neurology and Stroke Center, University Hospital Essen, Germany Hans.Diener@uk-essen.de.
authors.forename: Hans-Christoph
authors.initials: HC
authors.lastname: Diener
mesh_terms: D000925:Anticoagulants / Q000008:administration & dosage; D001281:Atrial Fibrillation / Q000150:complications / Q000175:diagnosis / Q000191:economics*; D002544:Cerebral Infarction / Q000175:diagnosis / Q000191:economics* / Q000517:prevention & control; D003362:Cost-Benefit Analysis / Q000379:methods; D017048:Health Care Costs; D006801:Humans; D008991:Monitoring, Physiologic / Q000191:economics* / Q000295:instrumentation*; D019057:Quality-Adjusted Life Years; D016032:Randomized Controlled Trials as Topic; D012008:Recurrence; D016896:Treatment Outcome; D006113:United Kingdom
chemical_list: D000925:Anticoagulants
keywords: Atrial fibrillation; cost-effectiveness analysis; cryptogenic stroke; economics; insertable cardiac monitor; oral anticoagulation therapy