Cardiac monitor insertion after cryptogenic stroke may be cost-effective in US
Immediate insertion of a cardiac monitor following first cryptogenic stroke was cost-effective in the U.S. compared with delayed implantation after 30-day Holter monitoring, according to a study.
In the study published in the Journal of Comparative Effectiveness Research, detection of atrial fibrillation with an insertable cardiac monitor (Reveal XT, Medtronic) after a stroke of indeterminate source, although more expensive upfront, was more cost-effective compared with delayed implantation or standard care due to the odds of detecting AF within 30 days of stroke.
“The challenge for devices is to show cost-effectiveness data over a prolonged period of time in a population of patients so that you know that your investment at baseline pays off over the course of time and pays back if you like,” Klaus Witte, MD, FRCP, FESC, FACC, senior lecturer and consultant cardiologist at the Leeds Institute for Cardiovascular and Metabolic Medicine at the University of Leeds, U.K., told Healio. “The other thing is that everything we do is slightly more expensive. People always say, ‘If you get the population healthy, you will save money.’ That is wrong. If you get the population healthy, they will live longer and end up costing more money in due course. So, health economics and cost-effectiveness analysis are important because there are so many pressures on health care services to know the best places to invest our money.”
For this analysis, researchers modeled lifetime costs and quality-adjusted life-years for three cardiac monitoring strategies after cryptogenic stroke. These strategies included cardiac monitor insertion immediately after cryptogenic stroke; delayed insertion after Holter monitoring; and standard care with intermittent ECG and Holter monitoring. Patient characteristics and detection efficacy were based on data from the CRYSTAL-AF trial.
“The implantable cardiac monitor is a little device that you stick under the skin and it’s a very small procedure. However, there is this slight hesitancy by some of my colleagues to try and delay it or avoid it altogether, partly because of the upfront cost and partly because it is an invasive procedure and many of them are stroke physicians, so they’re not familiar with putting in monitors,” Witte told Healio.
“There’s this trend that has occurred where physicians choose to do monitoring before they put in the devices,” Witte said in an interview. “Maybe with a 30-day monitor, there is a small likelihood of identification of atrial fibrillation in those patients. But if you take 100 people, and stick a patch on all of them, you have had to pay for that patch in 100 people, knowing that it will only identify a tiny proportion of those patients that would have been identified with the loop recorder. But at the end of 30 days, you still have to put the loop recorder into the other remaining patients because you haven’t excluded AF in them, you just haven’t found it yet.”
Researchers found that the immediate use of an insertable cardiac monitor, compared with standard care, showed an incremental benefit of 0.198 QALYs and 0.226 life-years, a reduction of 60 strokes per 1,000 patients and an incremental cost of $6,211. According to the study, these benefits were driven by the 3 years of insertable cardiac monitoring before removal due to the device meeting its battery life expectancy.
The strategy of immediate cardiac monitor implantation after stroke of unknown origin was also associated with lower stroke event costs and lower long-term health-related costs, according to the study.
Compared with standard care, immediate cardiac monitor insertion demonstrated an incremental cost‐effectiveness ratio (ICER) of $31,345 per QALY and $27,438 per life-year gained.
Compared with delayed insertion after Holter monitoring, the strategy of immediate cardiac monitor insertion after cryptogenic stroke was associated with an additional 0.001 QALYs and cost, on average, $135 less over a patient’s lifetime.
Moreover, for patients who underwent delayed cardiac monitor implantation, the 7-day costs totaled $233,300 per 1,000 patients and detected just 3% of patients who were ultimately diagnosed with AF.
“One of the things that I wanted to do as part of this research was to model it if we follow the less invasive doctor’s trend of doing some monitoring first, before we allocate them all to the loop recorder,” Witte told Healio. “If you do that, you end up paying a huge amount of money for however many patches, knowing that 80% or more are going to need a loop recorder anyway.
“It was inferior in terms of cost-effectiveness. It was more expensive to do that for a given outcome because you’ve got to pay for all of the monitors and you lose very few of the loop recorders after the 30 days,” Witte said in an interview. “In other words, you avoid a loop recorder in very few patients. It is a common misconception that we can avoid putting a loop recorder in if we monitor people for a month beforehand. A vast majority of patients will need a loop recorder eventually, so you should jolly well get on and do it early.”
In a subgroup analysis of higher-risk patients, the ICER was higher in patients with CHADS2 scores of 2 ($53,492 ) and 3 ($38,415) compared with the entire cohort ($31,345). Among patients with CHADS2 scores of 4 to 6, the ICER decreased to $19,514 per QALY gained, according to the study.
“The primary take-home message for clinicians is the same message that I would make for payers in society,” Witte told Healio. “The upfront investment of a loop recorder in somebody who’s had a stroke makes sense because you are putting a good process in place that will identify future risk, allowing you to intervene before the second stroke occurs with a very well-proven intervention, namely anticoagulation for atrial fibrillation. Given that around 30% of people with this type of stroke go on to have atrial fibrillation, whether it’s permanent or intermittent, the benefits of anticoagulation are proven.”