title: Potential Cost-Effectiveness of Ambulatory Cardiac Rhythm Monitoring After Cryptogenic Stroke.
abstract: Prolonged ambulatory ECG monitoring after cryptogenic stroke improves detection of covert atrial fibrillation, but its long-term cost-effectiveness is uncertain.
  
  
  
  We estimated the cost-effectiveness of noninvasive ECG monitoring in patients aged ≥55 years after a recent cryptogenic stroke and negative 24-hour ECG. A Markov model used observed rates of atrial fibrillation detection and anticoagulation from a randomized controlled trial (EMBRACE) and the published literature to predict lifetime costs and effectiveness (ischemic strokes, hemorrhages, life-years, and quality-adjusted life-years [QALYs]) for 30-day ECG (primary analysis) and 7-day or 14-day ECG (secondary analysis), when compared with a repeat 24-hour ECG.
  
  
  
  Prolonged ECG monitoring (7, 14, or 30 days) was predicted to prevent more ischemic strokes, decrease mortality, and improve QALYs. If anticoagulation reduced stroke risk by 50%, 30-day ECG (at a cost of USD $447) would be highly cost-effective ($2000 per QALY gained) for patients with a 4.5% annual ischemic stroke recurrence risk. Cost-effectiveness was sensitive to stroke recurrence risk and anticoagulant effectiveness, which remain uncertain, especially at higher costs of monitoring. Shorter duration (7 or 14 days) monitoring was cost saving and more effective than an additional 24-hour ECG; its cost-effectiveness was less sensitive to changes in ischemic stroke risk and treatment effect.
  
  
  
  After a cryptogenic stroke, 30-day ECG monitoring is likely cost-effective for preventing recurrent strokes; 14-day monitoring is an attractive value alternative, especially for lower risk patients. These results strengthen emerging recommendations for prolonged ECG monitoring in secondary stroke prevention. Cost-effectiveness in practice will depend on careful patient selection.
authors.affiliation: From the Centre for Excellence in Economic Analysis Research (CLEAR), Toronto, ON, Canada (J.H.E.Y, J.S.H.); Applied Health Research Centre, Toronto, ON, Canada (K.E.T.); HUB Research Solutions, Li Ka Shing Centre for Healthcare Analytics Research and Training (LKS-CHART) (M.M.), Li Ka Shing Knowledge Institute, Toronto, ON, Canada (A.L.); St. Michael's Hospital, Toronto, ON, Canada (P.D.); Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital; School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa; Institute of Clinical and Evaluative Sciences (ICES UOttawa), ON, Canada (K.T.); Institute of Health Policy, Management, and Evaluation (J.S.H., M.M., A.L.), Dalla Lana School of Public Health (K.E.T.), Leslie Dan Faculty of Pharmacy (J.S.H., M.M.), Division of Neurology (D.J.G.), and Department of Medicine (M.M., P.D., A.L., D.J.G.), University of Toronto, ON, Canada; Department of Public Health Sciences and Center for Healthcare Policy and Research, University of California, Davis, CA (J.S.H.); Division of Neurology, Department of Medicine, McMaster University, Hamilton, ON, Canada (M.S.); and Division of Neurology, Department of Medicine, Hurvitz Brain Sciences Program, and Regional Stroke Centre, Sunnybrook Health Sciences Centre and Sunnybrook Research Institute, Toronto, ON, Canada (D.J.G.).
authors.forename: Jean Hai Ein
authors.initials: JH
authors.lastname: Yong
authors.affiliation: From the Centre for Excellence in Economic Analysis Research (CLEAR), Toronto, ON, Canada (J.H.E.Y, J.S.H.); Applied Health Research Centre, Toronto, ON, Canada (K.E.T.); HUB Research Solutions, Li Ka Shing Centre for Healthcare Analytics Research and Training (LKS-CHART) (M.M.), Li Ka Shing Knowledge Institute, Toronto, ON, Canada (A.L.); St. Michael's Hospital, Toronto, ON, Canada (P.D.); Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital; School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa; Institute of Clinical and Evaluative Sciences (ICES UOttawa), ON, Canada (K.T.); Institute of Health Policy, Management, and Evaluation (J.S.H., M.M., A.L.), Dalla Lana School of Public Health (K.E.T.), Leslie Dan Faculty of Pharmacy (J.S.H., M.M.), Division of Neurology (D.J.G.), and Department of Medicine (M.M., P.D., A.L., D.J.G.), University of Toronto, ON, Canada; Department of Public Health Sciences and Center for Healthcare Policy and Research, University of California, Davis, CA (J.S.H.); Division of Neurology, Department of Medicine, McMaster University, Hamilton, ON, Canada (M.S.); and Division of Neurology, Department of Medicine, Hurvitz Brain Sciences Program, and Regional Stroke Centre, Sunnybrook Health Sciences Centre and Sunnybrook Research Institute, Toronto, ON, Canada (D.J.G.).
authors.forename: Kednapa
authors.initials: K
authors.lastname: Thavorn
authors.affiliation: From the Centre for Excellence in Economic Analysis Research (CLEAR), Toronto, ON, Canada (J.H.E.Y, J.S.H.); Applied Health Research Centre, Toronto, ON, Canada (K.E.T.); HUB Research Solutions, Li Ka Shing Centre for Healthcare Analytics Research and Training (LKS-CHART) (M.M.), Li Ka Shing Knowledge Institute, Toronto, ON, Canada (A.L.); St. Michael's Hospital, Toronto, ON, Canada (P.D.); Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital; School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa; Institute of Clinical and Evaluative Sciences (ICES UOttawa), ON, Canada (K.T.); Institute of Health Policy, Management, and Evaluation (J.S.H., M.M., A.L.), Dalla Lana School of Public Health (K.E.T.), Leslie Dan Faculty of Pharmacy (J.S.H., M.M.), Division of Neurology (D.J.G.), and Department of Medicine (M.M., P.D., A.L., D.J.G.), University of Toronto, ON, Canada; Department of Public Health Sciences and Center for Healthcare Policy and Research, University of California, Davis, CA (J.S.H.); Division of Neurology, Department of Medicine, McMaster University, Hamilton, ON, Canada (M.S.); and Division of Neurology, Department of Medicine, Hurvitz Brain Sciences Program, and Regional Stroke Centre, Sunnybrook Health Sciences Centre and Sunnybrook Research Institute, Toronto, ON, Canada (D.J.G.).
authors.forename: Jeffrey S
authors.initials: JS
authors.lastname: Hoch
authors.affiliation: From the Centre for Excellence in Economic Analysis Research (CLEAR), Toronto, ON, Canada (J.H.E.Y, J.S.H.); Applied Health Research Centre, Toronto, ON, Canada (K.E.T.); HUB Research Solutions, Li Ka Shing Centre for Healthcare Analytics Research and Training (LKS-CHART) (M.M.), Li Ka Shing Knowledge Institute, Toronto, ON, Canada (A.L.); St. Michael's Hospital, Toronto, ON, Canada (P.D.); Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital; School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa; Institute of Clinical and Evaluative Sciences (ICES UOttawa), ON, Canada (K.T.); Institute of Health Policy, Management, and Evaluation (J.S.H., M.M., A.L.), Dalla Lana School of Public Health (K.E.T.), Leslie Dan Faculty of Pharmacy (J.S.H., M.M.), Division of Neurology (D.J.G.), and Department of Medicine (M.M., P.D., A.L., D.J.G.), University of Toronto, ON, Canada; Department of Public Health Sciences and Center for Healthcare Policy and Research, University of California, Davis, CA (J.S.H.); Division of Neurology, Department of Medicine, McMaster University, Hamilton, ON, Canada (M.S.); and Division of Neurology, Department of Medicine, Hurvitz Brain Sciences Program, and Regional Stroke Centre, Sunnybrook Health Sciences Centre and Sunnybrook Research Institute, Toronto, ON, Canada (D.J.G.).
authors.forename: Muhammad
authors.initials: M
authors.lastname: Mamdani
authors.affiliation: From the Centre for Excellence in Economic Analysis Research (CLEAR), Toronto, ON, Canada (J.H.E.Y, J.S.H.); Applied Health Research Centre, Toronto, ON, Canada (K.E.T.); HUB Research Solutions, Li Ka Shing Centre for Healthcare Analytics Research and Training (LKS-CHART) (M.M.), Li Ka Shing Knowledge Institute, Toronto, ON, Canada (A.L.); St. Michael's Hospital, Toronto, ON, Canada (P.D.); Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital; School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa; Institute of Clinical and Evaluative Sciences (ICES UOttawa), ON, Canada (K.T.); Institute of Health Policy, Management, and Evaluation (J.S.H., M.M., A.L.), Dalla Lana School of Public Health (K.E.T.), Leslie Dan Faculty of Pharmacy (J.S.H., M.M.), Division of Neurology (D.J.G.), and Department of Medicine (M.M., P.D., A.L., D.J.G.), University of Toronto, ON, Canada; Department of Public Health Sciences and Center for Healthcare Policy and Research, University of California, Davis, CA (J.S.H.); Division of Neurology, Department of Medicine, McMaster University, Hamilton, ON, Canada (M.S.); and Division of Neurology, Department of Medicine, Hurvitz Brain Sciences Program, and Regional Stroke Centre, Sunnybrook Health Sciences Centre and Sunnybrook Research Institute, Toronto, ON, Canada (D.J.G.).
authors.forename: Kevin E
authors.initials: KE
authors.lastname: Thorpe
authors.affiliation: From the Centre for Excellence in Economic Analysis Research (CLEAR), Toronto, ON, Canada (J.H.E.Y, J.S.H.); Applied Health Research Centre, Toronto, ON, Canada (K.E.T.); HUB Research Solutions, Li Ka Shing Centre for Healthcare Analytics Research and Training (LKS-CHART) (M.M.), Li Ka Shing Knowledge Institute, Toronto, ON, Canada (A.L.); St. Michael's Hospital, Toronto, ON, Canada (P.D.); Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital; School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa; Institute of Clinical and Evaluative Sciences (ICES UOttawa), ON, Canada (K.T.); Institute of Health Policy, Management, and Evaluation (J.S.H., M.M., A.L.), Dalla Lana School of Public Health (K.E.T.), Leslie Dan Faculty of Pharmacy (J.S.H., M.M.), Division of Neurology (D.J.G.), and Department of Medicine (M.M., P.D., A.L., D.J.G.), University of Toronto, ON, Canada; Department of Public Health Sciences and Center for Healthcare Policy and Research, University of California, Davis, CA (J.S.H.); Division of Neurology, Department of Medicine, McMaster University, Hamilton, ON, Canada (M.S.); and Division of Neurology, Department of Medicine, Hurvitz Brain Sciences Program, and Regional Stroke Centre, Sunnybrook Health Sciences Centre and Sunnybrook Research Institute, Toronto, ON, Canada (D.J.G.).
authors.forename: Paul
authors.initials: P
authors.lastname: Dorian
authors.affiliation: From the Centre for Excellence in Economic Analysis Research (CLEAR), Toronto, ON, Canada (J.H.E.Y, J.S.H.); Applied Health Research Centre, Toronto, ON, Canada (K.E.T.); HUB Research Solutions, Li Ka Shing Centre for Healthcare Analytics Research and Training (LKS-CHART) (M.M.), Li Ka Shing Knowledge Institute, Toronto, ON, Canada (A.L.); St. Michael's Hospital, Toronto, ON, Canada (P.D.); Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital; School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa; Institute of Clinical and Evaluative Sciences (ICES UOttawa), ON, Canada (K.T.); Institute of Health Policy, Management, and Evaluation (J.S.H., M.M., A.L.), Dalla Lana School of Public Health (K.E.T.), Leslie Dan Faculty of Pharmacy (J.S.H., M.M.), Division of Neurology (D.J.G.), and Department of Medicine (M.M., P.D., A.L., D.J.G.), University of Toronto, ON, Canada; Department of Public Health Sciences and Center for Healthcare Policy and Research, University of California, Davis, CA (J.S.H.); Division of Neurology, Department of Medicine, McMaster University, Hamilton, ON, Canada (M.S.); and Division of Neurology, Department of Medicine, Hurvitz Brain Sciences Program, and Regional Stroke Centre, Sunnybrook Health Sciences Centre and Sunnybrook Research Institute, Toronto, ON, Canada (D.J.G.).
authors.forename: Mike
authors.initials: M
authors.lastname: Sharma
authors.affiliation: From the Centre for Excellence in Economic Analysis Research (CLEAR), Toronto, ON, Canada (J.H.E.Y, J.S.H.); Applied Health Research Centre, Toronto, ON, Canada (K.E.T.); HUB Research Solutions, Li Ka Shing Centre for Healthcare Analytics Research and Training (LKS-CHART) (M.M.), Li Ka Shing Knowledge Institute, Toronto, ON, Canada (A.L.); St. Michael's Hospital, Toronto, ON, Canada (P.D.); Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital; School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa; Institute of Clinical and Evaluative Sciences (ICES UOttawa), ON, Canada (K.T.); Institute of Health Policy, Management, and Evaluation (J.S.H., M.M., A.L.), Dalla Lana School of Public Health (K.E.T.), Leslie Dan Faculty of Pharmacy (J.S.H., M.M.), Division of Neurology (D.J.G.), and Department of Medicine (M.M., P.D., A.L., D.J.G.), University of Toronto, ON, Canada; Department of Public Health Sciences and Center for Healthcare Policy and Research, University of California, Davis, CA (J.S.H.); Division of Neurology, Department of Medicine, McMaster University, Hamilton, ON, Canada (M.S.); and Division of Neurology, Department of Medicine, Hurvitz Brain Sciences Program, and Regional Stroke Centre, Sunnybrook Health Sciences Centre and Sunnybrook Research Institute, Toronto, ON, Canada (D.J.G.).
authors.forename: Andreas
authors.initials: A
authors.lastname: Laupacis
authors.affiliation: From the Centre for Excellence in Economic Analysis Research (CLEAR), Toronto, ON, Canada (J.H.E.Y, J.S.H.); Applied Health Research Centre, Toronto, ON, Canada (K.E.T.); HUB Research Solutions, Li Ka Shing Centre for Healthcare Analytics Research and Training (LKS-CHART) (M.M.), Li Ka Shing Knowledge Institute, Toronto, ON, Canada (A.L.); St. Michael's Hospital, Toronto, ON, Canada (P.D.); Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital; School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa; Institute of Clinical and Evaluative Sciences (ICES UOttawa), ON, Canada (K.T.); Institute of Health Policy, Management, and Evaluation (J.S.H., M.M., A.L.), Dalla Lana School of Public Health (K.E.T.), Leslie Dan Faculty of Pharmacy (J.S.H., M.M.), Division of Neurology (D.J.G.), and Department of Medicine (M.M., P.D., A.L., D.J.G.), University of Toronto, ON, Canada; Department of Public Health Sciences and Center for Healthcare Policy and Research, University of California, Davis, CA (J.S.H.); Division of Neurology, Department of Medicine, McMaster University, Hamilton, ON, Canada (M.S.); and Division of Neurology, Department of Medicine, Hurvitz Brain Sciences Program, and Regional Stroke Centre, Sunnybrook Health Sciences Centre and Sunnybrook Research Institute, Toronto, ON, Canada (D.J.G.). david.gladstone@sunnybrook.ca.
authors.forename: David J
authors.initials: DJ
authors.lastname: Gladstone
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001281:Atrial Fibrillation / Q000175:diagnosis* / Q000209:etiology / Q000503:physiopathology; D002545:Brain Ischemia / Q000150:complications / Q000191:economics* / Q000503:physiopathology; D003362:Cost-Benefit Analysis; D015716:Electrocardiography, Ambulatory / Q000191:economics*; D006801:Humans; D008875:Middle Aged; D008962:Models, Theoretical; D019057:Quality-Adjusted Life Years; D055502:Secondary Prevention; D020521:Stroke / Q000150:complications / Q000191:economics* / Q000503:physiopathology
keywords: anticoagulant; atrial fibrillation; electrocardiography; secondary prevention; stroke