Marshall, Deborah A., Levy, Adrian R., Vidaillet, Humberto, Fenwick, Elisabeth, Slee, April, Blackhouse, Gordon, Greene, H. Leon, Wyse, D. George, Nichol, Graham, and O'Brien, Bernie J.
Background: Atrial fibrillation is the most common type of sustained cardiac arrhythmia, but recent trials have identified no clear advantage of rhythm control ever rate control. Consequently, economic factors often play a role in guiding treatment selection. Objective: To estimate the cost-effectiveness of rhythm-control versus rate-control strategies for atrial fibrillation in the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM). Design: Retrospective economic evaluation. Nonparametric boot-strapping was used to estimate the distribution of incremental costs and effects on the cost-effectiveness plane. Data Sources: Data on survival and use of health care resources ware obtained for all 4060 AFFIRM participants. Unit costs were estimated from various U.S. databases. Target Population: patients with atrial fibrillation who were 65 years of age or who had other risk factors for stroke or death, similar to those enrolled in AFFIRM. Time Horizon: Mean follow-up of 3.5 years. Perspective: Third-party payer. Interventions: Management of patients with atrial fibrillation with antiarrhythmic drugs (rhythm control) compared with drugs that control heart rate (rate control). Outcome Measures: Mean survival, resource use, costs, and cost-effectiveness. Results of Base-Case Analysis: A mean survival gain of 0.08 year (P = 0.10) was observed for rate control. Patients in the rate-control group used fewer resources (hospital days, pacemaker procedures, cardioversions, and short-stay and emergency department visits). Rate control costs $5077 less per person than rhythm control. Results of Sensitivity Analysis: Cost savings ranged from $2189 to $5481 per person. Rhythm control was mere costly and less effective than rate control in 95% of the bootstrap replicates over a wide range of cost assumptions. Limitations: Resource use was limited to key items collected in AFFIRM, and the results are generalizable only to similar patient populations with atrial fibrillation. Conclusion: Rate control is a cost-effective approach to the management of atrial fibrillation compared with maintenance of sinus rhythm in patients with atrial fibrillation similar to thOse enrolled in AFFIRM.