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. 2018 Jun;105(6):1697-1702.
doi: 10.1016/j.athoracsur.2017.12.029. Epub 2018 Jan 31.

Amiodarone Protocol Provides Cost-Effective Reduction in Postoperative Atrial Fibrillation

J Hunter Mehaffey  1 , Robert B Hawkins  1 , Matthew Byler  1 , Judy Smith  1 , John A Kern  1 , Irving Kron  1 , Gorav Ailawadi  1 , Tanya Wanchek  2 , Leora T Yarboro  3
Affiliations

Amiodarone Protocol Provides Cost-Effective Reduction in Postoperative Atrial Fibrillation

J Hunter Mehaffey et al. Ann Thorac Surg. 2018 Jun.

Abstract

Background: Postoperative atrial fibrillation (POAF) after cardiac operations results in a significant increase in morbidity, mortality, and health care costs. Prophylactic amiodarone has been shown to reduce the incidence of POAF; however, the cost-effectiveness of a protocol-driven approach remains unknown.

Methods: All patients with a Society of Thoracic Surgeons risk score enrolled in a prophylactic amiodarone protocol (n = 153) were propensity score matched 1:3 with patients before protocol implementation (n = 3,574). Multivariate logistic and linear regressions assessed the relative risks (POAF reduction and adverse medication effects) in the matched cohort of amiodarone therapy and costs, respectively. TreeAge cost-effectiveness software (TreeAge Software, Inc, Williamstown, MA) modeled the effects of prophylactic amiodarone costs, complication rates, and quality of life.

Results: Of patients eligible for the prophylactic amiodarone protocol, 94.3% (281 of 298) were enrolled. Prophylactic amiodarone significantly reduced the rate of POAF (25.7% vs 16.8%, p < 0.0001). A total of 600 matched patients demonstrate no baseline differences in demographics, comorbidities, disease state, or operative factors, with a significant reduction in POAF without an increase in other associated complications. With the use these adjusted estimates, the prophylactic amiodarone protocol demonstrated a cost savings of $458 per patient. Sensitivity analysis confirmed the protocol is cost-effective for all protocol-related POAF risk reductions below an odds ratio of 0.726.

Conclusions: Implementation of a prophylactic amiodarone protocol significantly reduced risk-adjusted rates of POAF, with a cost savings of $458 per patient. This analysis demonstrates how rigorous quantitative analysis can evaluate the benefits of quality improvement projects.

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Figures

Figure 1
Figure 1
Propensity Score Matching. Demonstrates odds ratios with 95% confidence intervals contributed by each variable in the propensity score matching algorithm.
Figure 2
Figure 2
TreeAge Cost-Effectiveness Model. Decision tree with estimated costs, POAF rates, adverse event rates and outcome utilities.
Figure 3
Figure 3
One-Way Sensitivity Analysis. One-way sensitivity analysis demonstrates the model is only sensitive to variation in the odds ratio of POAF reduction provided by a prophylactic amiodarone protocol above 0.726
Figure 4
Figure 4
Two-Way Sensitivity Analysis. Two-way sensitivity analysis varying both cost of POAF and odds ratio of POAF reduction with amiodarone demonstrates a prophylactic amiodarone protocol is cost effective at most estimates. Blue indicates amiodarone Prophylaxis is more cost effective while Orange indicates when it is not more cost effective. The 95% CI were used to vary the axes.
See this image and copyright information in PMC

Comment in

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