Cost effectiveness of left atrial appendage closure with the Watchman device for atrial fibrillation patients with absolute contraindications to warfarin

Abstract

AimsAtrial fibrillation (AF) patients with contraindications to oral anticoagulation have had few options for stroke prevention. Recently, a novel oral anticoagulant, apixaban, and percutaneous left atrial appendage closure (LAAC) have emerged as safe and effective therapies for stroke risk reduction in these patients. This analysis assessed the cost effectiveness of LAAC with the Watchman device relative to apixaban and aspirin therapy in patients with non-valvular AF and contraindications to warfarin therapy.Methods and resultsA cost-effectiveness model was constructed using data from three studies on stroke prevention in patients with contraindications: the ASAP study evaluating the Watchman device, the ACTIVE A trial of aspirin and clopidogrel, and the AVERROES trial evaluating apixaban. The cost-effectiveness analysis was conducted from a German healthcare payer perspective over a 20-year time horizon. Left atrial appendage closure yielded more quality-adjusted life years (QALYs) than aspirin and apixaban by 2 and 4 years, respectively. At 5 years, LAAC was cost effective compared with aspirin with an incremental cost-effectiveness ratio (ICER) of €16 971. Left atrial appendage closure was cost effective compared with apixaban at 7 years with an ICER of €9040. Left atrial appendage closure was cost saving and more effective than aspirin and apixaban at 8 years and remained so throughout the 20-year time horizon.ConclusionsThis analysis demonstrates that LAAC with the Watchman device is a cost-effective and cost-saving solution for stroke risk reduction in patients with non-valvular AF who are at risk for stroke but have contraindications to warfarin.

Barriers for a Wider Use of Left Atrial Appendage Occlusion as an Alternative to Oral Anticoagulation

“…However, it should be the weaker argument against LAAC. Different studies have demonstrated the cost-effectiveness of the LAAC procedure for NVAF [2,3,15]. What's more, all of them have demonstrated its superiority over the NOACs.…”

“…The ICER per QALY gained of LAAC over warfarin has been calculated as low as $3,432 [15]. A very interesting study [3] e) The same group of investigators performed a similar analysis [2] in patients with absolute contraindications to warfarin. The selected comparators for the LAAC were aspirin plus clopidogrel [18] and apixaban [14].…”

Cost-Effectiveness of Left Atrial Appendage Occlusion

“…11 Interestingly, the economics of LAA occlusion therapy using the Watchman device relative to both warfarin and novel oral anticoagulants (NOACs) has been the subject of several prior economic analyses. [12][13][14] When examining model-based economic analyses of medical care involving chronic disease therapies (such as AF), 2 points are worth keeping in mind. First, before considering any cost data, attention should be directed to the clinical effectiveness story reflected in the model and how that relates to the understanding of effectiveness based on empirical trial data.…”

Left Atrial Appendage Closure for Stroke Prevention is Safe and Effective in Selected Patients with Atrial Fibrillation

“…LAA closure is associated with an upfront procedural cost that is offset later due to the absence of the cost of oral AC therapy and associated complications. 13 Recently, Panikker et al 58 published a cost-impact analysis from randomized clinical trial studies and real-world experience comparing the cost of LAA closure using the WATCHMANt (Boston Scientific) with available oral anticoagulants. The study showed that LAA closure with the WATCHMANt (Boston Scientific) in a real-world setting may result in lower stroke and major bleeding rates than that reported in clinical trials.…”

“…Some studies have suggested that this approach may be cost effective in the long run when compared with long-term AC. 12,13 LAA exclusion therapies are evolving. Improvements in device design and increasing operator experience have significantly improved the procedural safety profile of LAA exclusion devices.…”