(VP046) EVALUATING THE COST-EFFECTIVENESS OF FIRST-LINE CRYOBALLOON ABLATION VERSUS ANTIARRHYTHMIC DRUG THERAPY FOR THE TREATMENT OF PAROXYSMAL ATRIAL FIBRILLATION FROM A CANADIAN HEALTHCARE PAYER PERSPECTIVE

Background: Three randomized controlled trials recently demonstrated that pulmonary vein isolation with cryoballoon ablation reduces atrial arrhythmia recurrence compared with antiarrhythmic drug (AAD) therapy in patients with symptomatic paroxysmal atrial fibrillation (PAF). We leveraged this data to develop a cost-effectiveness model (CEM) of first-line cryoablation compared with first-line AADs for PAF, from a Canadian healthcare payer’s perspective.

METHODS AND RESULTS: Clinical data from 703 individuals with symptomatic PAF recruited into Cryo-FIRST, STOP AF First, and EARLY-AF (NCT01803438; NCT03118518; NCT02825979) were analysed to estimate key clinical parameters for the CEM. Published literature or clinical expert opinion was used to populate the remaining model parameters. The CEM used a decision tree in the initial one-year trial period to distribute individuals into health states. A Markov model, with a three-month cycle length, tracked the movement of individuals between health states over the remaining 40-year time horizon. Costs were set at 2023 Canadian dollars and health benefits were expressed as quality-adjusted life years (QALYs). Costs and health benefits were discounted at 3% annually. Parameter uncertainty was explored using probabilistic sensitivity analysis (PSA).

Over a lifetime, across both treatment arms, individuals are expected to receive a total of approximately 1.2 ablations. Patients in the cryoablation arm had a 45% relative decrease in the time spent in AF health states and a 47% significant (p < 0.001) reduction in the average three-monthly rate of AF recurrence compared with AADs. Following initial treatment, the average monthly rate of ablation is reduced by 73% (p < 0.001) and there is a 4.3% (p=0.025) increase in health-related quality of life (HRQoL) as measured by the EQ-5D-3L in the cryoablation arm. The probabilistic results indicate that, over a 40-year time horizon, an individual treated with first-line cryoablation accrues less costs (-$3,800) and more QALYs (0.19) compared with first-line optimized AADs and is therefore considered dominant (Table 1). First-line cryoablation has a 99.9% probability of being cost-effective at a willingness-to-pay threshold of $50,000 per QALY.

Scenario analyses included replacing calculated utility decrements with European Heart Rhythm Association (EHRA) class-based decrements from previous literature and including an initial blanking period which delayed the recording of AF recurrences until 3 months post initial treatment. Under each scenario the probability of cost-effectiveness is 100.0% and 99.0%, at $50,000 per QALY, respectively.

Conclusion: From a Canadian healthcare payer’s perspective, first-line rhythm control with cryoballoon ablation is cost-effective (dominant) when compared with AADs.