Economic evaluation in cardiac electrophysiology: Determining the value of emerging technologies

Abstract

Cardiac electrophysiology is a constantly evolving speciality that has benefited from technological innovation and refinements over the past several decades. Despite the potential of these technologies to reshape patient care, their upfront costs pose a challenge to health policymakers who are responsible for the assessment of the novel technology in the context of increasingly limited resources. In this context, it is critical for new therapies or technologies to demonstrate that the measured improvement in patients' outcomes for the cost of achieving that improvement is within conventional benchmarks for acceptable health care value. The field of Health Economics, specifically economic evaluation methods, facilitates this assessment of value in health care. In this review, we provide an overview of the basic principles of economic evaluation and provide historical applications within the field of cardiac electrophysiology. Specifically, the cost-effectiveness of catheter ablation for both atrial fibrillation (AF) and ventricular tachycardia, novel oral anticoagulants for stroke prevention in AF, left atrial appendage occlusion devices, implantable cardioverter defibrillators, and cardiac resynchronization therapy will be reviewed.

Keywords: CRT-D; ICD (implantable cardioverter-defibrillator); ablation < electrophysiology; anticoagulation (AC); atrial fibrilation (AF); cardiac electrophysiogy; cardiac resynchronization therapy–defibrillator; cost effectiveness analysis (CEA); economic evaluation (cost effectiveness).

Figure 1

Cost-effectiveness plane. The horizontal axis represents the difference in benefits between the two therapies (e.g., difference in quality-adjusted life expectancy) and the vertical axis represents the difference in the cost. Quadrant II of the plane represents a situation where a new treatment “dominates” or is always acceptable than the comparator treatment; it reflects a situation where the new therapy is less costly and more effective. The opposite occurs in Quadrant IV, where the existing therapy dominates the new treatment. Quadrant I is where a new therapy is both more effective and most costly. If the incremental benefits are attained for acceptable incremental costs (this relationship is represented by the slope of the dotted line), then the new treatment is acceptable. [Reproduced from EP Europace 2011; 13(Suppl_2):ii3–ii8 with permission].

Figure 2

Incremental cost-effectiveness plane for comparing ablation with drug therapy for the entire CABANA cohort (catheter ablation vs. Antiarrhythmic Drug Therapy for Atrial Fibrillation; N = 2204; A) and the heart failure subgroup with New York Heart Association class ≥II symptoms (n = 778; B). Estimates of incremental costs and quality-adjusted life-years (QALYs) are shown (1 blue circle for each of 5,000 bootstrap samples). Quadrant I represents scenarios where ablation is more costly and less effective, Quadrant II represents scenarios where ablation is more costly and effective, Quadrant III represents scenarios where ablation is less costly and less effective, and Quadrant IV represents scenarios where ablation is less costly and more effective. The willingness-to-pay thresholds of $50,000 and $100,000 per QALY gained are represented as the slope of the green and red lines, respectively. Scenarios that fall below these willingness-to-pay-thresholds are considered economically attractive. (Reproduced from Circulation. 2022;146:535–547 with permission).

Figure 3

Considerations that may influence health policy decisions in addition to cost-effectiveness.