Catheter Ablation ‘Good Value’ in CABANA Economic Analysis

Radiofrequency ablation for atrial fibrillation (AF) is an “economically attractive” option compared with drug therapy, according to a new cost-effectiveness analysis of the CABANA trial.

Presented last week at the Heart Rhythm Society 2021 Scientific Sessions, the prespecified analysis showed that the incremental cost-effectiveness ratio (ICER) for ablation was $57,433 per quality-adjusted life-year (QALY) gained, which is in line with current thresholds for affordability, say researchers.

“This meets the threshold for good-value care in the United States,” said lead researcher Derek Chew, MD (Duke Clinical Research Institute, Durham, NC), during a late-breaking clinical trial session. In the United States, the American College of Cardiology and American Heart Association consider treatments with an ICER ranging from $50,000 to $150,000 per QALY to be of intermediate value (less than $50,000 is considered high value and more than $150,000 to be poor value). 

Chew pointed out that CABANA missed its primary endpoint—radiofrequency ablation did not significantly reduce all-cause mortality, disabling stroke, serious bleeding, or cardiac arrest when compared with drug therapy in 2,204 patients with new-onset or undertreated AF. However, there were significant improvements in quality of life, freedom from AF recurrence, and AF burden. 

Economic considerations for catheter ablation to improve quality of life or reduce symptom burden are important in this era of escalating healthcare costs and value-based care, said Chew. “With whatever expensive therapy we’re proposing to our patients, we want to make sure it has good value,” he said.

Also Good Value in HF Patients

Lifetime costs of ablation and drug therapy with rate and/or rhythm control were $150,987 and $135,594, respectively. The number of life-years gained with ablation was estimated to be 12.63 and 12.54 with drug therapy. Based on respective QALYs of 11.01 and 10.74 for ablation and drug therapy, the ICER for ablation compared with medical therapy was deemed economically viable.

“The cost-effectiveness was driven by quality-of-life gains,” said Chew. “When we looked at the life expectancies between the two groups—ablation versus drug therapy—there really was no difference, which is line with the primary study results.”

In a subgroup of 778 patients with heart failure in CABANA—where the primary endpoint was reduced with ablation, as was all-cause mortality—the ICER was $54,321 per QALY gained. Here, the cost-effectiveness of ablation versus drug therapy was driven by differences in mortality as well as quality of life, said Chew.

Speaking during the late-breaking session, Mark Link, MD (UT Southwestern Medical Center, Dallas, TX), praised the study investigators for the new data, noting that a number of CABANA subanalyses are starting to emerge from the main trial.

But in terms of the economic analysis, Link, as well as discussant Kimberley Selzman, MD (University of Utah, Salt Lake City), questioned why the costs of catheter ablation and medical therapy were so similar. In response, Chew said the majority of the cost differences between ablation and drug therapy accrued in the first year of follow-up, which was mainly attributable to the cost of the procedure. The high crossover rate to ablation (27.5%) increased the costs in the drug therapy arm, Chew said. For that reason, Link suggested, it might be worthwhile to see an economic analysis based on patients who received the assigned treatment (per protocol).

“I agree it’s not the formal way to evaluate a trial, but it’s more a real-world analysis,” said Link.