Cost-effectiveness of 7-day-Holter monitoring alone or in combination with transthoracic echocardiography in patients with cerebral ischemia

Felix Mayer,Raoul Stahrenberg,Rolf Wachter,Janine Biermann,Jürgen Wasem,Sarah Mostardt,Frank Edelmann,Alexander Goehler,Klaus Gröschel,Anja Neumann,Jan Liman

doi:10.1007/s00392-013-0601-2

Abstract

Background and purpose Prolonged Holter monitoring of patients with cerebral ischemia increases the detection rate of paroxysmal atrial fibrillation (PAF); this leads to improved antithrombotic regimens aimed at preventing recurrent ischemic strokes. The aim of this study was to compare a 7-day-Holter monitoring (7-d-Holter) alone or in combination with prior selection via transthoracic echocardiography (TTE) to a standard 24-h-Holter using a cost-utility analysis.MethodsLifetime cost, quality-adjusted life years (QALY), and incremental cost-effectiveness ratios (ICER) were estimated for a cohort of patients with acute cerebral ischemia and no contraindication to oral anticoagulation. A Markov model was developed to simulate the long-term course and progression of cerebral ischemia considering the different diagnostic algorithms (24-h-Holter, 7-d-Holter, 7-d-Holter after preselection by TTE). Clinical data for these algorithms were derived from the prospective observational Find-AF study (ISRCTN 46104198).ResultsPredicted lifelong discounted costs were 33,837 € for patients diagnosed by the 7-d-Holter and 33,852 € by the standard 24-h-Holter. Cumulated QALYs were 3.868 for the 7-d-Holter compared to 3.844 for the 24-h-Holter. The 7-d-Holter dominated the 24-h-Holter in the base-case scenario and remained cost-effective in extensive sensitivity analysis of key input parameter with a maximum of 8,354 €/QALY gained. Preselecting patients for the 7-d-Holter had no positive effect on the cost-effectiveness.ConclusionsA 7-d-Holter to detect PAF in patients with cerebral ischemia is cost-effective. It increases the detection which leads to improved antithrombotic regimens; therefore, it avoids recurrent strokes, saves future costs, and decreases quality of life impairment. Preselecting patients by TTE does not improve cost-effectiveness.

Highlights

Stroke poses a heavy economic burden, accounting for *2 to 7 % of total health expenditures that is equivalent to 0.15–0.36 % of the gross domestic product of western societies [1,2,3]
We aimed to evaluate the cost-effectiveness of three diagnostic strategies to detect paroxysmal atrial fibrillation (PAF) after acute cerebral ischemia: (a) standard 24-h-Holter monitoring (24-h-Holter), (b) 7-d-Holter, or (c) 7-d-Holter in a subgroup only, preselected by transthoracic echocardiography (TTE) (TTE/7-d-Holter)
In the base-case scenario, the discounted quality-adjusted life expectancy in a 68-year-old patient with acute ischemic stroke (IS) or transient ischemic attack (TIA) ranged from 3.833 quality-adjusted life years (QALY) for patients with 24-h-Holter to 3.842 QALYs with TTE/7-d-Holter and 3.844 QALYs with 7-d-Holter

Summary

Introduction

Stroke poses a heavy economic burden, accounting for *2 to 7 % of total health expenditures that is equivalent to 0.15–0.36 % of the gross domestic product of western societies [1,2,3]. We aimed to evaluate the cost-effectiveness of three diagnostic strategies to detect PAF after acute cerebral ischemia: (a) standard 24-h-Holter monitoring (24-h-Holter), (b) 7-d-Holter, or (c) 7-d-Holter in a subgroup only, preselected by TTE (TTE/7-d-Holter). Holter monitoring of patients with cerebral ischemia increases the detection rate of paroxysmal atrial fibrillation (PAF); this leads to improved antithrombotic regimens aimed at preventing recurrent ischemic strokes. Background mortality was modeled using age specific mortality rates adjusted for the increased risk of dying after cerebral ischemia [21]. These values reflect 6-month event rates after the initial event (Table 1) [22].

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