COST-EFFECTIVENESS OF TRANSESOPHAGEAL ECHOCARDIOGRAPHIC-GUIDED CARDIOVERSION - A DECISION-ANALYTIC MODEL FOR PATIENTS ADMITTED TO THE HOSPITAL WITH ATRIAL-FIBRILLATION

Objectives. Using a decision-analytic model, we sought to examine the cost-effectiveness of three strategies for cardioversion of patients a dmitted to the hospital with atrial fibrillation. Background. Transeso phageal echocardiographic (TEE)-guided cardioversion has been proposed as a method for early cardioversion of patients with atrial fibrillat ion. The cost-effectiveness of this approach, relative to conventional therapy, has nut been studied. Methods. We ascertained the cost per q uality-adjusted life-year (QALY) of three strategies: 1) conventional therapy-transthoracic echocardiography (TTE) and warfarin therapy for 1 month before cardioversion; 2) initial TTE, followed by EE and early cardioversion if no thrombus is detected; 3) initial TEE, with early cardioversion if no thrombus is detected. With strategies 2 and 3, if a thrombus is seen, follow-up TEE is performed. If no thrombus is seen , cardioversion is then performed. All strategies utilized anticoagula tion before and extending for 1 month after cardioversion. Life expect ancy, utilities (quality-of-life weights) and event probabilities were ascertained from published reports. Cost estimates were based on publ ished data and hospital accounting information. Results. Transesophage al echocardiographic-guided early cardiversion (strategy 3: cost $2,77 4 QALY 8.49) dominates TTE/ TEE-guided cardioversion (strategy 2: cost $3,106, QALY 8.48) and conventional therapy (strategy 1: cost $3,070, QALY 8.48) because it is the least costly with similar effectiveness, Sensitivity analyses demonstrated that TEE guided cardioversion (stra tegy 3 dominates conventional therapy if the risk of stroke after TEE negative for atrial thrombus is slightly less than that after conventi onal therapy (baseline estimate 0.8%). The results also depend on the risk of major hemorrhage hut are less sensitive to baseline estimates of morbidity from TEE, cost of TTE, cost of hospital admission for car dioversion and utilities for health states. Conclusions. On the basis of a decision-analytic model, TEE-guided early cardioversion, without TTE, is a reasonable cost-saving alternative to conventional therapy f or patients admitted to the hospital with atrial fibrillation, Such a strategy appears particularly beneficial for patients with an increase d risk of hemorrhagic complications. Future clinical studies examining the TEE strategy should consider eliminating initial TTE and carefull y assess both the thromboembolic and hemorrhagic risk. (C) 1997 by the American College of Cardiology