D-PO01-NC-04 - Cost-effectiveness Of Insertable Cardiac Monitors To Identify Atrial Fibrillation After Cryptogenic Stroke In The United States (ID 827)
Background: Insertable cardiac monitors (ICMs) are more likely than standard of care (SoC) intermittent external ECG monitors to detect atrial fibrillation (AF) in patients with cryptogenic stroke (CS). Anticoagulation is well proven to decrease recurrent stroke risk in patients with documented AF.
Objective: The aim of this study was to evaluate the cost-effectiveness of using an ICM to detect new AF in CS patients in a US healthcare setting.
Methods: Using patient characteristics and AF detection rates from the randomized CRYSTAL-AF trial, a lifetime Markov model was developed to assess the cost-effectiveness of ICM in comparison to SoC, from a U.S. payer perspective. SoC was based on the frequency of ECG and Holter monitoring observed in the trial. Three-year AF detection rates for ICM and SoC were 30% and 3%, respectively. AF detection resulted in a switch from aspirin to a NOAC, unless precluded by prior bleeds. Risks of ischemic strokes and bleeding events were based on cerebrovascular risk as well as the safety and efficacy of the treatment received. All costs and effects were discounted at 3% annually.
Results: ICM was associated with a gain of 0.20 quality-adjusted life years (QALYs) compared to SoC (6.99 vs. 6.79). This was driven by higher incidence of anticoagulation and a consequent reduction in lifetime ischemic strokes (580 vs. 640 events per 1,000 patients - avoidance of 60 events per 1,000 patients), outweighing an increase in major bleeding events (447 vs. 414). It was projected that 17 ICMs would need to be inserted to prevent 1 ischemic stroke. Total lifetime per-patient costs were $54,479 and $47,891 in the ICM and SoC arms, respectively. The incremental cost-effectiveness ratio was $33,165 per QALY gained compared to SoC. The cost-effectiveness of the ICM improved as the CHADS2 score increased in this population.
Conclusion: ICMs are highly likely to be a cost-effective diagnostic tool for the prevention of recurrent stroke in a U.S. cryptogenic stroke population. This strategy was most cost-effective in patients at highest risk for recurrent ischemic stroke.