title: Cost-Effectiveness of Left Atrial Appendage Closure for Stroke Prevention in Atrial Fibrillation Patients With Contraindications to Anticoagulation.
abstract: Percutaneous left atrial appendage closure (LAAC) is increasingly performed as an alternative to oral anticoagulation (OAC) in patients with nonvalvular atrial fibrillation (AF). We sought to evaluate the cost-effectiveness of treating OAC contraindicated patients with LAAC compared with aspirin alone.
  
  
  
  A probabilistic patient-level Markov microsimulation model with a lifetime horizon was performed to assess the discounted lifetime costs, quality-adjusted life years, and incremental cost-effectiveness ratio of LAAC compared with aspirin for patients with AF with contraindications to OAC. Baseline characteristics were based on a published multicenter Canadian LAAC experience. Clinical events included stroke, bleeding, myocardial infarction, and procedure-related complications. Event rates for stroke and bleeding were based on the CHA2DS2-VASc and HAS-BLED scores. The relative efficacies of LAAC and aspirin, as well as utility scores, were obtained from the published literature. Canadian procedural and long-term costs were obtained from the Ontario Case Costing Initiative and the Ontario Ministry of Health and Long Term Care.
  
  
  
  Aspirin was less effective than LAAC (4.25 ± 0.53 vs 4.66 ± 0.34 quality-adjusted life years, respectively). The average discounted lifetime cost was CAD$30,748 ± 11,600 for LAAC and $38,974 ± 18,783 for aspirin. Thus, LAAC was dominant, being more effective and less expensive. Our results were robust with a relatively low degree of uncertainty, as LAAC was the preferred option in more than 90% of simulations at a willingness-to-pay threshold of $50,000.
  
  
  
  LAAC is a novel stroke preventative therapy for nonvalvular AF and is a cost-effective alternative to aspirin in patients with contraindications to OAC.
authors.affiliation: Division of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada. Electronic address: jsaw@mail.ubc.ca.
authors.forename: Jacqueline
authors.initials: J
authors.lastname: Saw
authors.affiliation: Schulich Heart Center, Division of Cardiology, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Maria C
authors.initials: MC
authors.lastname: Bennell
authors.affiliation: Schulich Heart Center, Division of Cardiology, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Sheldon M
authors.initials: SM
authors.lastname: Singh
authors.affiliation: Schulich Heart Center, Division of Cardiology, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada; Institute for Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, Ontario, Canada.
authors.forename: Harindra C
authors.initials: HC
authors.lastname: Wijeysundera
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants; D001241:Aspirin / Q000191:economics* / Q000627:therapeutic use; D020517:Atrial Appendage / Q000601:surgery; D001281:Atrial Fibrillation / Q000188:drug therapy / Q000191:economics* / Q000601:surgery*; D000075202:Contraindications; D003362:Cost-Benefit Analysis; D005260:Female; D006801:Humans; D008297:Male; D008390:Markov Chains; D018803:Models, Economic; D010975:Platelet Aggregation Inhibitors / Q000191:economics* / Q000627:therapeutic use; D019057:Quality-Adjusted Life Years; D020521:Stroke / Q000517:prevention & control*; D060205:Therapeutic Occlusion / Q000191:economics / Q000295:instrumentation
chemical_list: D000925:Anticoagulants; D010975:Platelet Aggregation Inhibitors; D001241:Aspirin