Is Screening for Atrial Fibrillation Cost Effective?
January 15, 2023
By Michael H. Crawford, MD
Professor of Medicine, Lucy Stern Chair in Cardiology, University of California, San Francisco
SYNOPSIS: Self-screening for atrial fibrillation in elderly individuals could lead to lower stroke rates, prevent bleeding-related hospitalizations, and save money.
SOURCE: Lyth J, Svennberg E, Bernfort L, et al. Cost-effectiveness of population screening for atrial fibrillation: The STROKESTOP study. Eur Heart J 2022; Nov 9: ehac547. doi: 10.1093/eurheartj/ehac547. [Online ahead of print].
During STROKESTOP, researchers randomized almost 28,000 individuals age 75 or 76 years in Sweden to an atrial fibrillation (AF) screening group and a control group. Investigators followed all patients for almost seven years. Among the 13,979 invited to screen for AF, 7,165 participated. The study showed the primary combined endpoint of ischemic or hemorrhagic stroke, systemic embolism, bleeding leading to hospitalization, and all-cause death, was significantly reduced in the screening group (P = 0.045).
The long-term follow-up of this randomized population provides new data for estimating the cost effectiveness of AF screening, which was a prespecified secondary endpoint. The screening participants received a hand-held ECG recorder and were instructed to perform 30-second recordings twice a day for two weeks. The AF endpoint was defined as one or more episodes lasting 30 seconds, or at least two episodes lasting 10 seconds to 29 seconds. The cost of clinical events was taken from the literature. The analysis was based on a Markov cohort model with a lifetime perspective. For every 1,000 individuals invited to screening, 77 gained life years, and 65 gained quality-adjusted life years (QALYs). Screening for AF in 1,000 individuals resulted in 10.6 fewer strokes (95% CI, -22 to 1.4) — 8.4 ischemic and 2.2 hemorrhagic — one more systemic embolism (95% CI, 1.9-4.1), and 2.9 fewer bleeding-related hospitalizations (95% CI, -18.2 to 13.1). The cost difference was €1.77 million lower in the screening invitation group. The result of 10,000 Monte Carlo simulations demonstrated screening for AF was cost effective for 99% and produced cost savings in 93% of simulations. The authors concluded screening an elderly population for AF is cost effective and efforts should be made to expand participation in such programs.
COMMENTARY
The STROKESTOP study authors used actual follow-up outcome data from their huge cohort. In addition, STROKESTOP included patients age 75 or 76 years, which is the age at which the risk of stroke increases significantly. Because they used actual clinical data, the authors shed light on why screening for AF leads to cost savings after three years. STROKESTOP showed this screening technique was low cost, oral anticoagulants were inexpensive, and there were fewer strokes.
One issue with STROKESTOP is the screening participation rate was low (51%). Still, the STROKESTOP authors used all those invited to participate in screening, regardless of whether they did. The authors estimated that if the participation rate was 65%, they would have added 2.6 QALYs at a cost of only €0.06 million. At a participation rate of 80%, the authors reported they would add eight QALYs at a cost of €0.08 million. Thus, the authors suggested efforts at increasing participation in AF screening would be cost effective.
There were some weaknesses. The authors reported no functional data on patients, and disability would add costs. Also, STROKESTOP was statistically significant for the combined endpoint; the individual components were not. The estimated costs were from Sweden, so they may not be applicable in other parts of the world. In addition, screening participation was higher in rural areas than in urban ones, which was not factored into the data analysis.
Screening high-risk patients for AF likely is cost effective. However, how should clinicians conduct the screening? What is the right age to target? What should be the screening’s intensity? Clinicians will have to answer these questions based on their situations. It is unlikely there will be a one-size-fits-all solution. Also, whether AF screening will achieve the acceptance rate of cancer screening is difficult to predict, partly because people know a positive result means anticoagulation.
Self-screening for atrial fibrillation in elderly individuals could lead to lower stroke rates, prevent bleeding-related hospitalizations, and save money.
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