Hospital Readmissions in US Atrial Fibrillation Patients
1Department of Medicine, University of California Irvine Medical Center, Irvine, CA 2Department of Evidence Based Medicine, sanofi-aventis Inc, Bridgewater, NJ 3Department of Health Economics and Outcomes Research, Novosys Health, Flemington, NJ. American journal of therapeutics
(Impact Factor: 1.13).
11/2012; 20(2). DOI: 10.1097/MJT.0b013e3182512c7e
The aim of the study was to examine the temporal readmission pattern, proportion of readmissions attributed to cardiovascular (CV) causes, and the duration and costs associated with readmission in hospitalized patients with atrial fibrillation/flutter (AF/AFL). This retrospective cohort study used medical claims data from the PharMetrics Patient-Centric database (IMS Health, Watertown, MA) between January 2007 and March 2008. The patients hospitalized with a primary diagnosis of AF/AFL and with ≥12 months' continuous medical and prescription coverage before and after the initial AF/AFL hospitalization were identified from this database. The main outcome measures were rehospitalization patterns [all-cause, all CV-related (including AF/AFL), and AF/AFL-related only], which were assessed over the 12-month post-index period, and costs of initial and subsequent AF/AFL-related hospitalizations that were compared. The study included 8035 patients with AF/AFL (mean age 66.1 years; 57.6% males). Rehospitalization was common (37.9% of patients), with the most frequent causes being CV (34.1%) and, specifically, AF/AFL-related (26.8%). The highest proportion of rehospitalizations occurred within 30 days of the initial hospitalization (25%). Readmissions with a primary diagnosis of AF/AFL (n = 1238) were significantly longer (4.0 vs. 3.6 days; P = 0.0229) and more costly (US$8966 vs. US$7080; P < 0.0001) than the index hospitalization. Hospitalized AF/AFL patients experience high rates of CV- and AF/AFL-related readmissions, particularly within the first 30 days. Subsequent AF/AFL-related readmissions incur higher costs than the initial AF/AFL hospitalization. Treatments resulting in reduced readmissions would improve patient outcomes, quality of life and the cost burden associated with AF/AFL.
Available from: Jay Lin
- "In clinical practice, AF/AFL patients at high thromboembolic risk, who represent prime candidates for dronedarone treatment, experience high rates of hospitalization, with approximately 40% requiring readmission within the first 12 months after their initial hospitalization for AF/AFL, resulting in a mean cost per AF hospitalization of US$7,476–8,493 [16, 28]. In keeping with the high volume and temporal pattern of cardiovascular admissions displayed by this high-risk patient population, the study findings suggest that the benefit of reduced hospital resource utilization associated with dronedarone is realized promptly, within 12 months of commencing treatment. "
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ABSTRACT: The ATHENA (A Placebo-Controlled, Double-Blind, Parallel Arm Trial to Assess the Efficacy of Dronedarone 400 mg bid for the Prevention of Cardiovascular Hospitalization or Death from Any Cause in Patients with Atrial Fibrillation/Atrial Flutter) trial demonstrated a significant reduction (26%) in the rate of first cardiovascular (CV) hospitalization in dronedarone-treated patients with paroxysmal or persistent atrial fibrillation/flutter (AF/AFL). ATHENA was the first trial to demonstrate a CV outcomes benefit, specifically reduced CV hospitalizations, with an antiarrhythmic drug. The objective of this study was to assess the impact of dronedarone treatment on healthcare resource utilization among real-world patients with AF/AFL in United States clinical practice.
This retrospective cohort study used claims data from the MarketScan(®) databases (Truven Health, Durham, NC, USA) to identify patients with ≥2 concurrent de novo pharmacy claims for dronedarone (≥180 days' total supply) between June 2009 and March 2011, and with an AF/AFL diagnosis and no heart failure-related hospitalization during the 12 months preceding the initial (index) dronedarone claim. Annualized inpatient and outpatient resource utilization were compared between the pre-index (baseline) and post-index (follow-up) periods.
In total, 5,656 AF/AFL patients were prescribed dronedarone for ≥6 months and were followed for mean (standard deviation) 11.9 (4.7) months. Reductions in mean numbers of annualized all-cause, CV- and AF-related hospitalizations (~40-45%), and emergency department visits (~30-45%) were realized. These benefits were offset by increases in office visits (~10-30%) and AF-related prescription claims (74%) after dronedarone initiation. The sub-cohort of patients switching to dronedarone from Prior Rhythm-Control therapy (n = 2,080) showed similar reductions in hospital and emergency department events.
This study suggests that dronedarone use in real-world practice, as in the ATHENA trial, results in substantial reductions in hospital admissions, both in first-line and second-line antiarrhythmic treatment settings.
Available from: Maciej Banach
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ABSTRACT: The prevalence of atrial fibrillation substantially increases after 70 years of age. However, the effect of rate-control versus rhythm-control strategies on outcomes in these patients remains unclear.
In the randomized Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial, 4060 patients (mean age 70 years, range 49-80 years) with paroxysmal and persistent atrial fibrillation were randomized to rate-control versus rhythm-control strategies. Of these, 2248 were 70-80 years, of whom 1118 were in the rate-control group. Propensity scores for rate-control strategy were estimated for each of the 2248 patients and were used to assemble a cohort of 937 pairs of patients receiving rate-control versus rhythm-control strategies, balanced on 45 baseline characteristics.
Matched patients had a mean age of 75 years; 45% were women, 7% were nonwhite, and 47% had prior hospitalizations due to arrhythmias. During 3.4 years of mean follow-up, all-cause mortality occurred in 18% and 23% of matched patients in the rate-control and rhythm-control groups, respectively (hazard ratio [HR] associated with rate control, 0.77; 95% confidence interval [CI], 0.63-0.94; P = .010). HRs (95% CIs) for cardiovascular and noncardiovascular mortality associated with rate control were 0.88 (0.65-1.18) and 0.62 (0.46-0.84), respectively. All-cause hospitalization occurred in 61% and 68% of rate-control and rhythm-control patients, respectively (HR 0.76; 95% CI, 0.68-0.86). HRs (95% CIs) for cardiovascular and noncardiovascular hospitalization were 0.66 (0.56-0.77) and 1.07 (0.91-1.27), respectively.
In septuagenarian patients with atrial fibrillation, compared with rhythm-control, a rate-control strategy was associated with significantly lower mortality and hospitalization.
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Patients with persistent or longstanding atrial fibrillation have modest success achieving sinus rhythm with catheter ablation or rhythm control medications. Their high risk of stroke, bleed, and heart failure leads to significant morbidity and health care costs. The convergent procedure has been shown to be successful in this population, with 80% of patients in sinus rhythm after 1 year. This study evaluated the cost-effectiveness of the convergent procedure, catheter ablation, and medical management for non-paroxysmal AF patients.
A Markov micro-simulation model was used to estimate costs and effectiveness from a payer perspective. Parameter estimates were from the literature. Three patient cohorts were simulated, representing lower, medium, and higher risks of stroke, bleed, heart failure, and hospitalization. Effects were estimated by quality-adjusted life-years (QALYs). Single-variable sensitivity analysis was performed.
After 5 years, convergent procedure patients averaged 1.10 procedures, with 75% of survivors in sinus rhythm; catheter ablation patients had 1.65 procedures, with 49% in sinus rhythm. Compared to medical management, catheter ablation and the convergent procedure were cost-effective for the lower risk (ICER <$35,000) and medium risk (ICER <$15,000) cohorts. The procedures dominated medical management for the higher risk cohort (lower cost and higher QALYs). The convergent procedure dominated catheter ablation for all risk cohorts. RESULTS were subject to simplifying assumptions and limited by uncertain factors such as long-term maintenance of sinus rhythm after successful procedure and incremental AF-associated event rates for AF patients relative to patients in sinus rhythm. In the absence of clinical trial data, convergent procedure efficacy was estimated with observational evidence. Limitations were addressed with sensitivity analyses and a moderate 5 year time horizon.
The convergent procedure results in superior maintenance of post-ablation sinus rhythm with fewer repeat ablation procedures compared to catheter ablation, leading to lower cost and higher QALYs after 5 years.
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