Costs saved a decade later compared to warfarin
Percutaneous left atrial appendage (LAA) closure with the Watchman device was cost-saving in the long-term, even after accounting for the uptick in stroke risk observed in one trial, researchers reported.
The high upfront cost of the Watchman procedure became cost-effective relative to warfarin by year 7 (at $48,674 per quality-adjusted life-year) and cost-saving at year 10 ($32,769 vs $33,286 in total costs), according to pooled data from the PROTECT AF and PREVAIL trials.
Compared against non-vitamin K antagonist oral anticoagulants (NOACs), LAA occlusion was a better value by year 5 ($23,960 vs $25,691), a group led by Vivek Reddy, MD, of Icahn School of Medicine at Mount Sinai in New York City, showed in a study published online in the Journal of the American Heart Association.
The researchers estimated the LAA occlusion group gained 0.60 quality-adjusted life-years more than warfarin patients did and 0.29 more than NOAC recipients over a lifetime.
"Despite the increased risk of ischemic stroke observed in the PREVAIL trial, LAA closure is cost-effective and cost saving relative to NOACs and warfarin when the full body of RCT [randomized controlled trial] data is taken into consideration," Reddy and colleagues concluded.
"LAA closure with the Watchman device is an economically viable stroke risk reduction strategy for patients with AF [atrial fibrillation] seeking an alternative to lifelong anticoagulation," they said.
Watchman placement has itself been associated with device thrombus-related stroke.
The study was based on a Markov model over a 20-year horizon. The model included 10,000 people, age 70, at moderate stroke and bleeding risk.
Researchers weighed Watchman costs against procedural complications and clinical event probabilities derived from 5-year data from PROTECT AF and PREVAIL. NOAC cost-effectiveness was based on published meta-analyses.
Reddy's group had previously reported that LAA occlusion achieved cost-effectiveness relative to warfarin and NOACs by years 7 and 5, respectively, based only on 4-year data from PROTECT AF.
The addition of PREVAIL and 1 year more of follow-up yielded the same results.
"Probabilistic sensitivity analysis results confirmed that when using pooled, long-term data, there is a high probability that LAA closure is cost-effective relative to warfarin and NOACs at 20 years (98% and 95%, respectively)," the investigators added.
Assuming older patients (age 75 and 80 at baseline), cost-effectiveness did not go away either.
The study authors acknowledged that there is no trial directly comparing LAA occlusion and NOACs and that they couldn't account for oral anticoagulant switching, discontinuing, or restarting. Additionally, their model assumed each participant would have no more than one adverse event every 3 months.
The study was supported by Boston Scientific.
— LAST UPDATED 07.02.2019
Journal of the American Heart Association
Source Reference: Reddy VY, et al "Cost-effectiveness of left atrial appendage closure for stroke reduction in atrial fibrillation: analysis of pooled, 5-year, long-term data" J Am Heart Assoc 2019; DOI: 10.1161/JAHA.118.011577.
Read the original article on Medpage Today: LAA Occluder PREVAILs in Cost-Effectiveness