PCV27 COST-EFFECTIVENESS OF INSERTABLE CARDIAC MONITORS VERSUS STANDARD OF CARE OR SHORT-TO-LONG-TERM ECG MONITORING TO IDENTIFY ATRIAL FIBRILLATION AFTER CRYPTOGENIC STROKE

Abstract

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 proven to decrease recurrent stroke risk in patients with documented AF. We aimed to evaluate the cost-effectiveness of immediate ICM at hospital discharge versus a ‘short-to-long-term monitoring’ (STLM) approach (7-day ECG monitor followed by ICM in patients remaining undiagnosed) and versus SoC, in a CS population. A lifetime Markov model assessed the cost-effectiveness of immediate ICM vs. STLM vs. SoC, from a US payer perspective. Patient characteristics and AF detection rates were based on the CRYSTAL-AF trial: three-year diagnostic yield was 30% with ICM and 3% in SoC; 1% of STLM patients are diagnosed with initial 7-day monitor. AF detection resulted in a change from aspirin to NOAC, unless precluded by prior bleeds. Subsequent risks of ischemic strokes and bleeding events were modeled based on published literature. Costs and effects were discounted at 3% annually. Immediate ICM was associated with a 0.20 quality-adjusted life year (QALY) gain compared to SoC (6.99 vs. 6.79) and $6,588 higher per-patient costs, resulting in an incremental cost-effectiveness ratio of $33,169 per QALY gained. ICM’s expected value improved with increased recurrent stroke risk. Compared to STLM, immediate ICM was associated with lower costs ($54,480 vs. $54,665), and a modest benefit in outcomes (gain of 0.0011 QALYs) making it economically dominant for AF detection. In sensitivity analysis, the immediate ICM approach remained cost-saving when varying the duration of initial short-term monitor (1-, 2-, 21-, and 30-days). ICMs are a cost-effective diagnostic tool for the prevention of recurrent stroke in a US cryptogenic stroke population. Immediate ICM was cost-saving compared to STLM, due to the cost and low diagnostic yield of short-term monitoring and delay in AF detection.