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Cost-Effectiveness of Radiofrequency Ablation for Supraventricular Tachycardia

Carol H.F. Cheng, BS; Gillian D. Sanders, PhD; Mark A. Hlatky, MD; Paul Heidenreich, MD, MS; Kathryn M. McDonald, MM; Byron K. Lee, MD; Mary S. Larson, MD; and Douglas K. Owens, MD, MS
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Copyright ©2004 by the American College of Physicians

Ann Intern Med. 2000;133(11):864-876. doi:10.7326/0003-4819-133-11-200012050-00010
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Background: Radiofrequency ablation is an established but expensive treatment option for many forms of supraventricular tachycardia. Most cases of supraventricular tachycardia are not life-threatening; the goal of therapy is therefore to improve the patient's quality of life.

Objective: To compare the cost-effectiveness of radiofrequency ablation with that of medical management of supraventricular tachycardia.

Design: Markov model.

Data Sources: Costs were estimated from a major academic hospital and the literature, and treatment efficacy was estimated from reports from clinical studies at major medical centers. Probabilities of clinical outcomes were estimated from the literature. To account for the effect of radiofrequency ablation on quality of life, assessments by patients who had undergone the procedure were used.

Target Population: Cohort of symptomatic patients who experienced 4.6 unscheduled visits per year to an emergency department or a physician's office while receiving long-term drug therapy for supraventricular tachycardia.

Time Horizon: Patient lifetime.

Perspective: Societal.

Interventions: Initial radiofrequency ablation, long-term antiarrhythmic drug therapy, and treatment of acute episodes of arrhythmia with antiarrhythmic drugs.

Outcome Measures: Costs, quality-adjusted life-years, life-years, and marginal cost-effectiveness ratios.

Results of Base-Case Analysis: Among patients who have monthly episodes of supraventricular tachycardia, radiofrequency ablation was the most effective and least expensive therapy and therefore dominated the drug therapy options. Radiofrequency ablation improved quality-adjusted life expectancy by 3.10 quality-adjusted life-years and reduced lifetime medical expenditures by $27 900 compared with long-term drug therapy. Long-term drug therapy was more effective and had lower costs than episodic drug therapy.

Results of Sensitivity Analysis: The findings were highly robust over substantial variations in assumptions about the efficacy and complication rate of radiofrequency ablation, including analyses in which the complication rate was tripled and efficacy was decreased substantially.

Conclusions: Radiofrequency ablation substantially improves quality of life and reduces costs when it is used to treat highly symptomatic patients. Although the benefit of radiofrequency ablation has not been studied in less symptomatic patients, a small improvement in quality of life is sufficient to give preference to radiofrequency ablation over drug therapy.


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Figure 1.
Schematic representation of the decision model.Top.RFABottom.AV

The square node at the left represents the therapy decision. If long-term drug therapy or episodic drug therapy is chosen, the patient's health state thereafter is simulated by a four-state Markov model, the follow-up subtree. In this follow-up subtree, each month, patients may experience an arrhythmic event leading to an unscheduled visit or no symptoms. The patient may die of other causes or survive and continue to be followed in the subtree. If electrophysiologic study and radiofrequency ablation ( ) are chosen, the patient may have no complications, procedural complications, or procedural death. If the patient survives the ablation, the patient enters the radiofrequency ablation results subtree. If radiofrequency ablation was successful, the arrhythmia may recur soon after the procedure. If the arrhythmia recurs, the patient undergoes a second ablation, with similar possible outcomes. If the radiofrequency ablation successfully cures the arrhythmia initially, the patient enters a Markov follow-up for the remainder of the lifetime. During follow-up, the patient may develop atrioventricular ( ) block or may continue to have events (albeit less frequently). If radiofrequency ablation failed, the patient receives the next best strategy, long-term drug therapy, and continues to receive it for the lifetime. If radiofrequency ablation induces permanent atrioventricular block, the patient is followed in a subtree (not shown) that accounts for the cost of a pacemaker. All patients are followed until death.

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Figure 2.
Years required to recoup costs of radiofrequency ablation, given different monthly costs of drug therapy.

The analysis includes all costs of medical therapy, including drug costs, physician visits, and treatment in emergency departments. Triangles represent a monthly drug cost of $10 (base case), squares represent a monthly drug cost of $50, and circles represent a monthly drug cost of $100. The vertical axis represents the number of arrhythmic events per year the patient experiences while receiving long-term drug therapy. The horizontal axis shows the number of years after radiofrequency ablation until the cumulative cost of that strategy would be less than the cost of the long-term drug strategy. Costs are recouped more quickly for patients who have more frequent arrhythmic events and for patients whose drug therapy is more expensive. The time to recoup costs for the base-case analysis is shown by the arrow.

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