Internal Medicine Resident University of Calgary, Alberta, Canada
Background: Early rhythm control of atrial fibrillation (AF) with catheter ablation within 1 year of AF diagnosis delays disease progression and reduces the risk of adverse cardiovascular outcomes. While prior studies indicate that catheter ablation is cost-effective compared to antiarrhythmic drugs for management of AF, there is limited economic data comparing an early ablation approach to the current standard of care. This study aimed to evaluate the impact of ablation timing on the cost-effectiveness of catheter ablation for treatment of new-onset AF.
METHODS AND RESULTS: A 3-arm decision-analytic Markov model compared the lifetime costs and health benefits of (a) early ablation (within 1 year of AF diagnosis), (b) delayed ablation (≥ 1 year), and (c) antiarrhythmic drug (AAD) therapy in a simulated cohort of patients with new onset atrial fibrillation. Model parameters were derived from existing clinical trials, meta-analyses and system-level healthcare databases. Outcomes included costs (2023 CAD), quality-adjusted life years (QALYs) and incremental cost effectiveness ratios (ICERs) from the perspective of the Canadian public healthcare payer. A strategy of early ablation accrued lifetime costs of $74,067 (95% CI $56,648 – $108,366) and 7.95 QALYs (95% CI 7.56 – 8.36) compared to $68,621 (95% CI $47,727 – $115,789) and 7.75 QALYs (95% CI 7.35 – 8.15) with AAD therapy. Compared to AAD therapy, early ablation yielded an ICER of $26,372 per QALY, with an 88% likelihood of cost-effectiveness at a $50,000/QALY gained willingness-to-pay threshold. When compared to AAD therapy alone, delayed ablation was associated with an ICER of $48,185/QALY gained. In the three-way analysis, delayed ablation was dominated by early ablation, offering lower health benefits at higher costs across all willingness-to-pay thresholds. Factors with the greatest impact on cost-effectiveness were the cost of ablation, effect of ablation on rehospitalization, and quality of life decrements associated with AF recurrence (Figure). A threshold analysis demonstrated that early ablation remained cost-effective below procedural costs of $16,440.
Conclusion: Catheter ablation is a cost-effective strategy for rhythm control in patients with new onset AF. However, the value proposition of ablation is influenced by timing, where early ablation provides greater health benefits at lower costs than delayed ablation. In the context of prolonged ablation wait times of over 1 year in Canada, these findings support prioritizing healthcare policy reform and resource reallocation to reduce wait times and enhance access to ablation.
