scholarly journals Improved outcome and cost effectiveness in ablation of persistent atrial fibrillation under general anaesthetic

2017 ◽  
Author(s):  
Claire A Martin ◽  
James P Curtain ◽  
Parag R Gajendragadkar ◽  
David A Begley ◽  
Simon P Fynn ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Cost Effectiveness ◽  
Cost Effective ◽  
Persistent Atrial Fibrillation ◽  
Atrial Arrhythmia ◽  
General Anaesthetic ◽  
List Type ◽  
Single Shot ◽  
Af Ablation ◽  
Improved Outcome

AbstractAimsOutcome of persistent atrial fibrillation (AF) ablation remains suboptimal. Techniques employed to reduce arrhythmia recurrence rate are more likely to be embraced if cost-effectiveness can be demonstrated. A single-centre observational study assessed whether use of general anaesthesia (GA) in persistent AF ablation improved outcome and was cost-effective.Methods292 patients undergoing first ablation procedures for persistent AF under conscious sedation or GA were followed. End points were freedom from listing for repeat ablation at 18 months and freedom from recurrence of atrial arrhythmia at one year.ResultsFreedom from atrial arrhythmia was higher in patients who underwent ablation under GA rather than sedation (63.9% vs 42.3%, HR 1.87, 95% CI: 1.23 to 2.86, p = 0.002). Significantly fewer GA patients were listed for repeat procedures (29.2% vs 42.7%, HR 1.62, 95% CI: 1.01 to 2.60, p = 0.044). Despite GA procedures costing slightly more, a saving of £177 can be made per patient in our centre for a maximum of 2 procedures if all persistent AF ablations are performed under GA.ConclusionsIn patients with persistent AF, it is both clinical and economically more effective to perform ablation under GA rather than sedation.What’s New?There is very little known regarding the clinical outcome of catheter ablation of AF under GA compared with sedation; to our knowledge there is one study only in paroxysmal AF and no studies examining cost effectiveness.This study shows that in patients with persistent AF, it is both clinical and economically more effective to perform ablation under GA rather than sedation.This study leads us to recommend the use of GA for the ablation of persistent AF. As PAF ablation is now increasingly being undertaken by single shot techniques which do not have the same requirements for analgesia and immobility, GA resources may be allocated for persistent AF ablation.

scholarly journals Improved outcome and cost effectiveness in ablation of persistent atrial fibrillation under general anaesthetic

EP Europace ◽  
2017 ◽  
Vol 20 (6) ◽  
pp. 935-942 ◽  
Author(s):  
Claire A Martin ◽  
James P Curtain ◽  
Parag R Gajendragadkar ◽  
David A Begley ◽  
Simon P Fynn ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Cost Effectiveness ◽  
Persistent Atrial Fibrillation ◽  
General Anaesthetic ◽  
Improved Outcome

scholarly journals Ablation of complex fractionated electrograms improves outcome in long standing persistent atrial fibrillation

2017 ◽  
Author(s):  
Claire A Martin ◽  
James P Curtain ◽  
Parag R Gajendragadkar ◽  
David A Begley ◽  
Simon P Fynn ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Atrial Tachycardia ◽  
Persistent Atrial Fibrillation ◽  
Atrial Arrhythmia ◽  
General Anaesthetic ◽  
Procedure Time ◽  
Substrate Modification ◽  
Linear Ablation ◽  
Complex Fractionated Electrogram ◽  
One Year

AbstractPurposeThere is controversy and sparse data on whether substrate based techniques in addition to pulmonary vein isolation (PVI) confer benefit in the catheter ablation of persistent atrial fibrillation (AF), especially if long standing. We performed an observational study to assess whether substrate based ablation improved freedom from atrial arrhythmia.Methods286 patients undergoing first ablation procedures for persistent AF with PVI only, PVI plus linear ablation, or PVI plus complex fractionated electrogram (CFAE) and linear ablation were followed. Primary end point was freedom from atrial arrhythmia at one year.ResultsMean duration of pre-procedure time in AF was 28+/-27 months. Freedom from atrial arrhythmia was higher with a PVI+CFAE+lines strategy then for PVI alone (HR 1.56, 95% CI: 1.04-2.34, p=0.032) but was not higher with PVI+lines. Benefit of substrate modification was conferred for pre-procedure times in AF of over 30 months. The occurrence of atrial tachycardia was higher when lines were added to the ablation strategy (HR 0.08, 95% CI: 0.01-0.59, p=0.014). Freedom from atrial arrhythmia at 1 year was higher with lower patient age, use of general anaesthetic (GA), normal or mildly dilated left atrium and decreasing time in AF.ConclusionsIn patients with long standing persistent AF of over 30 months duration, CFAE ablation resulted in improved freedom from atrial arrhythmia. Increased freedom from atrial arrhythmia occurs in patients who are younger and have smaller atria, and with GA procedures. Linear ablation did not improve outcome and resulted in a higher incidence of atrial tachycardia.

Abstract 18957: Modulation of Ganglionated Plexi as an Addition to Pv Isolation in Persistent Atrial Fibrillation Ablation

Circulation ◽  
2015 ◽  
Vol 132 (suppl_3) ◽  
Author(s):  
Sabine Ernst ◽  
Richard Underwood ◽  
Sonya Babu-Narayan ◽  
Simona Ben-Haim
Keyword(s):  
Atrial Fibrillation ◽  
3D Imaging ◽  
Imaging Study ◽  
Persistent Atrial Fibrillation ◽  
High Frequency Stimulation ◽  
Af Ablation ◽  
Road Map ◽  
Ganglionated Plexi ◽  
Individual Variations ◽  
Frequency Stimulation

Introduction: Catheter ablation of ganglionated plexi (GP) as an add on to pulmonary vein (PV) isolation has been reported to significantly improve outcome of atrial fibrillation (AF) ablation. In order to facilitate localization of these GPs, a novel imaging study is proposed that investigates the uptake of iodine-123 metaiodobenzylguanidine (mIBG, an analogon for norepinephrine) on the atrial level. This information is combined with 3D surface reconstruction from contrast computed tomography (cCT) or cardiac magnetic resonance (CMR). Methods: A total of 7 patients (5 male, mean age 64.3 yrs) with AF underwent mIBG nuclear studies using a dedicated solid state cardiac camera (D-SPECT, Spectrum Dynamics). Four patient had 4 persistent AF (3 prev. abl.) with less than 1 year of sustained AF, whereas 3 patient were in longstanding persistent AF (all prev. abl). The acquired data was merged with the 3D imaging and subsequently imported into the 3D electroanatomical mapping system (CARTO, Biosense Webster). During invasive AF ablations these sites were mapped to perform high frequency stimulation (HFS) to confirm GP locations. Results: In all pts, both the mIBG and CT scans were performed without any complications. Locations of high mIBG uptake corresponded to anatomical GP sites (LA & RA) in the majority of patients, but individual variations were observed. PV isolation was added in all but 1 pt (who had previous ablation) plus CFAE ablation if necessary. Follow-up of in median of 10.4 months demonstrated SR in all persistent AF patients (1 redo for atrial reentry). In patients with longstanding persistent AF: 2 pts are in SR (both AF at 1 week and 1 pt in AT at 6 weeks), while 1 pt remained in AF. Conclusion: The combination of mIBG and 3D imaging provides a novel type of “road map” for localizing GPs during AF ablation. As an add-on to PV (re-) isolation, this strategy was found to be beneficial for patients with persistent and longstanding persistent AF. Interestingly, pts with longstanding persistent AF (and multiple previous ablations) all recurred early in F/U but showed reversal to AT and finally SR at later stages. Further studies in larger patient cohorts need to confirm these initial observations.

scholarly journals Beyond ratios - flexible and resilient nurse staffing options to deliver cost-effective hospital care and address staff shortages: a simulation and economic modelling study

2020 ◽  
Author(s):  
Peter Griffiths ◽  
Christina Saville ◽  
Jane E Ball ◽  
Jeremy Jones ◽  
Thomas Monks
Keyword(s):  
Cost Effectiveness ◽  
Significant Proportion ◽  
Nurse Staffing ◽  
Cost Savings ◽  
Cost Effective ◽  
Adverse Outcomes ◽  
List Type ◽  
Economic Modelling ◽  
The Face ◽  
Hospital Wards

AbstractBackgroundIn the face of pressure to contain costs and make best use of scarce nurses, flexible staff deployment (floating staff between units and temporary hires) guided by a patient classification system may appear an efficient approach to meeting variable demand for care in hospitals.ObjectivesWe modelled the cost-effectiveness of different approaches to planning baseline numbers of nurses to roster on general medical/surgical units while using flexible staff to respond to fluctuating demand.Design and SettingWe developed an agent-based simulation model, where units move between being understaffed, adequately staffed or overstaffed as staff supply and demand, measured by the Safer Nursing Care Tool, varies. Staffing shortfalls are addressed firstly by floating staff from overstaffed units, secondly by hiring temporary staff. We compared a standard staffing plan (baseline rosters set to match average demand) with a ‘resilient’ plan set to match higher demand, and a ‘flexible’ plan, set at a lower level. We varied assumptions about temporary staff availability. We estimated the effect of unresolved low staffing on length of stay and death, calculating cost per life saved.ResultsStaffing plans with higher baseline rosters led to higher costs but improved outcomes. Cost savings from low baseline staff largely arose because shifts were left under staffed. Cost effectiveness for higher baseline staff was improved with high temporary staff availability. With limited temporary staff available, the resilient staffing plan (higher baseline staff) cost £9,506 per life saved compared to the standard plan. The standard plan cost £13,967 per life saved compared to the flexible (low baseline) plan. With unlimited temporary staff, the resilient staffing plan cost £5,524 per life saved compared to the standard plan and the standard plan cost £946 per life saved compared with the flexible plan. Cost-effectiveness of higher baseline staffing was more favourable when negative effects of high temporary staffing were modelled.ConclusionFlexible staffing can be guided by shift-by-shift measurement of patient demand, but proper attention must be given to ensure that the baseline number of staff rostered is sufficient.In the face of staff shortages, low baseline staff rosters with high use of flexible staff on hospital wards is not an efficient or effective use of nurses whereas high baseline rosters may be cost-effective. Flexible staffing plans that minimise the number of nurses routinely rostered are likely to harm patients because temporary staff may not be available at short notice.Study registration: ISRCTN 12307968Tweetable abstractEconomic model of hospital wards shows low baseline staff levels with high use of flexible staff are not cost-effective and don’t solve nursing shortages].What is already known?Because nursing is the largest staff group, accounting for a significant proportion of hospital’s variable costs, ward nurse staffing is frequently the target of cost containment measuresStaffing decisions need to address both the baseline staff establishment to roster, and how best to respond to fluctuating demand as patient census and care needs varyFlexible deployment of staff, including floating staff and using temporary hires, has the potential to minimise expenditure while meeting varying patient need, but high use of temporary staff may be associated with adverse outcomes.What this paper addsOur simulation shows that low baseline staff rosters that rely heavily on flexible staff increase the risk of patient death and provide cost savings largely because wards are often left short staffed under real world availability of temporary staff.A staffing plan set to meet average demand appears to be cost effective compared to a plan with a lower baseline but is still associated with frequent short staffing despite the use of flexible deployments.A staffing plan with a higher baseline, set to meet demand 90% of the time, is more resilient in the face of variation and may be highly cost effective

Abstract 200: Cost-Effectiveness of Newer Anticoagulants for Stroke Prevention in Atrial Fibrillation

2013 ◽  
Vol 6 (suppl_1) ◽  
Author(s):  
Brendan L Limone ◽  
William L Baker ◽  
Craig I Coleman
Keyword(s):  
Atrial Fibrillation ◽  
Cost Effectiveness ◽  
Stroke Prevention ◽  
Indirect Comparison ◽  
Cost Effective ◽  
The United States ◽  
Base Case ◽  
Treatment Comparison ◽  
Newer Anticoagulants ◽  
The Cost

Background: A number of new anticoagulants for stroke prevention in atrial fibrillation (SPAF) have gained regulatory approval or are in late-stage development. We sought to conduct a systematic review of economic models of dabigatran, rivaroxaban and apixaban for SPAF. Methods: We searched the Medline, Embase, National Health Service Economic Evaluation Database and Health Technology Assessment database along with the Tuft’s Registry through October 10, 2012. Included models assessed the cost-effectiveness of dabigatran (150mg, 110mg, sequential), rivaroxaban or apixaban for SPAF using a Markov model or discrete event simulation and were published in English. Results: Eighteen models were identified. All models utilized a lone randomized trial (or an indirect comparison utilizing a single study for any given direct comparison), and these trials were clinically and methodologically heterogeneous. Dabigatran 150mg was assessed in 9 of models, dabigatran 110mg in 8, sequential dabigatran in 9, rivaroxaban in 4 and apixaban in 4. Adjusted-dose warfarin (either trial-like, real-world prescribing or genotype-dosed) was a potential first-line therapy in 94% of models. Models were conducted from the perspective of the United States (44%), European countries (39%) and Canada (17%). In base-case analyses, patients typically were at moderate-risk of ischemic stroke, initiated anticoagulation between 65 and 73 years of age, and were followed for or near a lifetime. All models reported cost/quality-adjusted life-year (QALY) gained, and while 22% of models reported using a societal perspective, no model included costs of lost productivity. Four models reported an incremental cost-effectiveness ratio (ICER) for a newer anticoagulant (dabigatran 110mg (n=4)/150mg (n=2); rivaroxaban (n=1)) vs. warfarin above commonly reported willingness-to-pay thresholds. ICERs (in 2012US$) vs. warfarin ranged from $3,547-$86,000 for dabigatran 150mg, $20,713-$150,000 for dabigatran 110mg, $4,084-$21,466 for sequentially-dosed dabigatran and $23,065-$57,470 for rivaroxaban. In addition, apixaban was demonstrated to be an economically dominant strategy compared to aspirin and to be dominant or cost-effective ($11,400-$25,059) vs. warfarin. Based on separate indirect treatment comparison meta-analyses, 3 models compared the cost-effectiveness of these new agents and reported conflicting results. Conclusions: Cost-effectiveness models of newer anticoagulants for SPAF have been extensively published. Models have frequently found newer anticoagulants to be cost-effective, but due to the lack of head-to-head trial comparisons and heterogeneity in clinical characteristic of underlying trials and modeling methods, it is currently unclear which of these newer agents is most cost-effective.

Cost-effectiveness of mobile health-based integrated care for atrial fibrillation: Model development and data analysis (Preprint)

2021 ◽  
Author(s):  
Xueyan Luo ◽  
Wei Xu ◽  
Quan Yuan ◽  
Han Lai ◽  
Chunji Huang
Keyword(s):  
Atrial Fibrillation ◽  
Sensitivity Analysis ◽  
Cost Effectiveness ◽  
Integrated Care ◽  
Mobile Health ◽  
Cost Effective ◽  
Sensitivity Analyses ◽  
Base Case ◽  
Life Years ◽  
Mhealth Technology

BACKGROUND Mobile health (mhealth) technology is increasingly used in disease management. Using mhealth tools to integrate and streamline care was found to improve atrial fibrillation (AF) patients’ clinical outcomes. OBJECTIVE This study aimed to investigate the potential clinical and health economic outcomes of mhealth-based integrated care for AF from the perspective of a public healthcare provider in China. METHODS A Markov model was designed to compare outcomes of mhealth-based care and usual care in a hypothetical cohort of AF patients in China. The time horizon was 30 years with monthly cycles. Model outcomes measured were direct medical cost, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). Sensitivity analyses were conducted to examine the robustness of base-case results. RESULTS In the base-case analysis, mhealth-based care gained higher QALYs of 0.0818 with an incurred cost of USD1,778. Using USD33,438 per QALY (three times gross domestic product) as the willingness-to-pay threshold, mhealth-based care was cost-effective, with an ICER of USD21,739 per QALY. The one-way sensitivity analysis found compliance to mhealth-based care had the greatest impact on the ICER. In probabilistic sensitivity analysis, mhealth-based care was accepted as cost-effective in 80.91% of 10,000 iterations. CONCLUSIONS This study suggested that the use of mhealth technology in streamlining and integrating care for AF patients was cost-effective in China.

Abstract 15934: Comparison of Atrial Fibrillation Burden Reduction in Patients With Paroxysmal and Persistent Atrial Fibrillation Undergoing Cryoballoon Pulmonary Vein Isolation

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Dan L Musat ◽  
Nicolle S Milstein ◽  
Jacqueline Pimienta ◽  
Advay Bhatt ◽  
Tina C Sichrovsky ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Pulmonary Vein ◽  
Pulmonary Vein Isolation ◽  
Persistent Atrial Fibrillation ◽  
Loop Recorder ◽  
Similar Reduction ◽  
Af Ablation ◽  
Ablation Success ◽  
One Year ◽  
Af Recurrence

Background: Pulmonary vein isolation (PVI) is a cornerstone of atrial fibrillation (AF) ablation procedures to treat symptomatic AF. Ablation success is defined by absence of AF recurrence >30 seconds. However, reduction in AF burden (AFB) is also an important endpoint. Whether patients with paroxysmal (PAF) and persistent AF (PeAF) have similar reduction in AFB post-ablation is unknown. Objective: To compare the decrease in AFB following cryoballoon (CB) PVI in patients with PAF and PeAF. Methods: We enrolled consecutive pts with an implantable loop recorder (ILR) who subsequently underwent CB PVI. All patients were followed prospectively for at least one year, or until repeat ablation; we compared AFB pre and post-ablation. Results: The cohort included had 47 patients (66 ± 10 years; 32 [68%] male; PAF [n=23, 49%]; CHA 2 DS 2 -VASc 2.7 ± 1.7, 34 [72%] on AAD at the time of ablation). A median of 136 days [IQR 280, 73; minimum of 30 days] of ILR data pre-ablation were available. The median AFB for PAF was 4.7% [IQR 0.9, 14.8] and PeAF was 6.8% [IQR 1.1, 40.4]. After excluding a 3-month post-ablation blanking period, recurrent AF occurred in 12 (52%) PAF and 11 (46%) PeAF patients. The median AFB post-ablation for PAF and PeAF cohorts was 0.03%, [IQR 0, 0.3] and 0.04%, [IQR 0, 1.1], respectively. This represents a >99% reduction in AFB. Conclusion: Although 50% of patients undergoing CB PVI for PAF or PeAF had a recurrence of AF, there was >99% reduction in AFB in both groups. These data highlight the importance of using AFB burden as a marker of therapeutic efficacy post-AF ablation.

scholarly journals P886Long-standing persistent atrial fibrillation: The impact of intraprocedural AF termination on freedom of any atrial arrhythmia

EP Europace ◽  
2017 ◽  
Vol 19 (suppl_3) ◽  
pp. iii171-iii172
Author(s):  
M. Kottmaier ◽  
T. Reents ◽  
F. Bourier ◽  
S. Busch ◽  
V. Semmler ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Persistent Atrial Fibrillation ◽  
Atrial Arrhythmia ◽  
The Impact
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