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Cost-Effectiveness of Rhythm versus Rate Control in Atrial Fibrillation

Deborah A. Marshall, PhD; Adrian R. Levy, PhD; Humberto Vidaillet, MD; Elisabeth Fenwick, PhD; April Slee; Gordon Blackhouse, MSc; H. Leon Greene, MD; D. George Wyse, MD, PhD; Graham Nichol, MD; Bernie J. O'Brien, PhD†, and the AFFIRM and CORE Investigators*
[+] Article and Author Information

From McMaster University and St. Joseph's Hospital, Hamilton, Ontario, Canada; University of British Columbia, Vancouver, British Columbia, Canada; Marshfield Clinic, Marshfield, Wisconsin; University of York, York, United Kingdom; Axio Research Corporation, Seattle, Washington; University of Calgary, Calgary, Alberta, Canada; and University of Ottawa, Ottawa, Ontario, Canada.


Acknowledgments: The authors thank Mr. Tom Delea, Policy Analysis, Inc., for advice regarding costing. This paper is dedicated to our late mentor, colleague, coauthor, and friend, Bernie O'Brien.

Grant Support: AFFIRM was supported (contract N01-HC-55139) by the National Heart, Lung, and Blood Institute. The CORE study for the cost-effectiveness analysis is supported in part by the Canadian Institutes of Health Research Chronic Disease New Emerging Team Program, The Canadian Diabetes Association, The Kidney Foundation of Canada, the Heart and Stroke Foundation of Canada, and the Canadian Institutes of Health Research Institutes of Nutrition, Metabolism and Diabetes, Circulatory and Respiratory Health, and Gender and Health. Dr. Elisabeth Fenwick's postdoctoral fellowship was funded through a fellowship from Roche, Canada. Dr. Bernie J. O'Brien was supported by the Canadian Institutes of Health Research (CIHR). Dr. Graham Nichol is a Career Scientist of the Ontario Ministry of Health.

Potential Financial Conflicts of Interest: Consultancies: H. Vidaillet (Astra Zeneca); Honoraria: H. Vidaillet (Astra Zeneca); Grants received: G. Nichol (Medtronic Inc., Canadian Institutes of Health Research, Medtronic ERS, Cardiac Science, Zoll, Philips, National Heart, Lung, and Blood Institute); Grants pending: G. Nichol (Medtronic Inc., Medtronic ERS).

Requests for Single Reprints: Deborah Marshall, PhD, Center for Evaluation of Medicine, McMaster University, 25 Main Street West, Suite 2000, Hamilton, Ontario L6B 1H1, Canada; e-mail, marshd@mcmaster.ca.

Current Author Addresses: Dr. Marshall: Department of Clinical Epidemiology and Biostatistics, McMaster University, Centre for Evaluation of Medicines, 25 Main Street West, Suite 2000, Hamilton, Ontario L6B 1H1, Canada.

Dr. Levy: Department of Health Care and Epidemiology, University of British Columbia, St. Paul's Hospital, 620B-1081 Burrard Street, Vancouver, British Columbia V6Z 1Y6, Canada.

Dr. Vidaillet: Marshfield Clinic–Marshfield Center, 1000 North Oak Avenue, Marshfield, WI 54449.

Dr. Fenwick: Department of Economics and Related Studies and Centre for Health Economics, University of York, York Y0105DD, United Kingdom.

Ms. Slee and Dr. Greene: Axio Research Corporation, 2601 4th Avenue, Suite 200, Seattle, WA 98121.

Mr. Blackhouse: Program for Assessment of Technology in Health, McMaster University, 25 Main Street West, Suite 2000, Hamilton, Ontario L6B 1H1, Canada.

Dr. Wyse: Faculty of Medicine, University of Calgary, 3330 Hospital Drive Northwest, Calgary, Alberta T2N 4N1, Canada.

Dr. Nichol: University of Washington, Harborview Research and Training Center for Pre-Hospital Emergency Care, 325 Ninth Avenue, Seattle, WA 98104.

Author Contributions: Conception and design: D.A. Marshall, A.R. Levy, H. Vidaillet, E. Fenwick, D.G. Wyse, G. Nichol, B.J. O'Brien.

Analysis and interpretation of the data: D.A. Marshall, A.R. Levy, H. Vidaillet, E. Fenwick, A. Slee, G. Blackhouse, L. Greene, D.G. Wyse, G. Nichol, B.J. O'Brien.

Drafting of the article: D.A. Marshall, A.R. Levy, H. Vidaillet, D.G. Wyse, G. Nichol.

Critical revision of the article for important intellectual content: D.A. Marshall, A.R. Levy, H. Vidaillet, E. Fenwick, A. Slee, L. Greene, D.G. Wyse, G. Nichol, B.J. O'Brien.

Final approval of the article: D.A. Marshall, A.R. Levy, H. Vidaillet, E. Fenwick, D.G. Wyse, B.J. O'Brien.

Provision of study materials or patients: D.A. Marshall, H. Vidaillet, D.G. Wyse.

Statistical expertise: D.A. Marshall, A. Slee, G. Blackhouse.

Obtaining of funding: D.A. Marshall, A.R. Levy, L. Greene, D.G. Wyse.

Administrative, technical, or logistic support: D.A. Marshall.

Collection and assembly of data: D.A. Marshall, A.R. Levy, H. Vidaillet, L. Greene.


Ann Intern Med. 2004;141(9):653-661. doi:10.7326/0003-4819-141-9-200411020-00005
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This economic analysis of AFFIRM demonstrates that on the basis of conventional decision criteria (44), rhythm control is not cost-effective compared with rate control. AFFIRM demonstrated a nonsignificant trend toward reduced survival in patients with atrial fibrillation who attempt rhythm control compared with rate control. The present analysis demonstrated that rhythm control is consistently more expensive than rate control in such patients, and, consequently, rate control is the preferred alternative (rhythm control was dominated by rate control) on the basis of cost. An intervention that is less effective and more costly than its comparator is considered to be “dominated by” the alternative (16). These results were insensitive to changes in the cost estimates explored in the sensitivity analyses.

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Figure.
Scatter plot of estimated joint density of incremental costs and incremental effects of rhythm control versus rate control by bootstrap resampling (base case).
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Summary for Patients

Cost-Effectiveness of Rate Control vs. Rhythm Control for Patients with Atrial Fibrillation

The summary below is from the full report titled “Cost-Effectiveness of Rhythm versus Rate Control in Atrial Fibrillation.” It is in the 2 November 2004 issue of Annals of Internal Medicine (volume 141, pages 653-661). The authors are D.A. Marshall, A.R. Levy, H. Vidaillet, E. Fenwick, A. Slee, G. Blackhouse, H.L. Greene, D.G. Wyse, G. Nichol, B.J. O'Brien, and the AFFIRM and CORE Investigators.

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