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Impact of AF Burden on Health Care Costs and Utilization
Quick Takes
- CIED-recognized AF, especially if persistent AF, was associated with increased health care utilization in both the total and direct patient-incurred health care costs.
- Health care costs for AF were driven by increased rates of inpatient and outpatient encounters, heart failure hospitalizations, and AF-specific interventions (AF ablation, cardioversion, oral anticoagulant or antiarrhythmic drug prescription, or hospitalization for initiation).
- Patients with AF had higher overall unadjusted total health care costs than those without AF ([mean ± SD: $53,944 ± $235,469] vs. [mean ± SD: $41,156 ± $96,769]).
Study Questions:
How does atrial fibrillation (AF) detection by cardiac implantable electronic device (CIED) impact health care utilization and costs?
Methods:
This was a retrospective review of the Optum Clinformatics U.S. insurance claims and the Medtronic CareLink databases between 2015–2020, which were evaluated to obtain patient-specific demographic, cost, and utilization data for the presence of incremental AF burden categories (paroxysmal [pAF], persistent [PeAF], and permanent [PermAF] AF) over the first 6 months post-CIED implantation, and to compare the overall annualized total health care cost associated with presence of device-recognized AF versus patients without AF. Incremental AF burden analyses were adjusted for geographical region, insurance type, and CHA2DS2-VASc score and year of implant.
Secondary endpoints included the annualized cost and adjusted overall and patient incurred-cost (sum of the patient deductible, copay, and coinsurance amounts) between the AF burden and the annualized cost by type of CIED (cardiac resynchronization therapy-pacemaker [CRT-P], cardiac resynchronization therapy-defibrillator [CRT-D], dual-chamber implantable cardioverter-defibrillator [ICD], dual-chamber pacemaker [PPM], or implantable cardiac monitor [ICM]) implanted. Analyses of these endpoints were used to evaluate the impact on the rates of health care utilization (number and cost of encounters in various health care settings, number of inpatient hospitalization days), AF-related interventions, and AF-related adverse events between groups.
Results:
Patients included in the study (N = 21,391) were aged 72.9 ± 10.9 years; 56.3% were male; 3.16% with ICM only; and 36.5% with presence of AF. The overall adjusted annualized costs in patients in AF (pAF [76.5%], PeAF [14.7%], and PermAF [8.8%]) were all greater than in patients with no AF (p for all < 0.001). The average annualized health care cost was $45,817 ± 161,861 (median [IQR]: $18,166 [$7,497-$45,813]). Patients with AF (mean ± SD: $53,944 ± $235,469; median [IQR]: $21,308 [$9,148-$52,665]) had higher overall unadjusted total health care costs than those without AF (mean ± SD: $41,156 ± $96,769; median [IQR]: $16,481 [$6,741-$41,861]) (cost ratio, 1.22; 95% confidence interval, 1.18-1.26; p < 0.001). While the overall annualized cost in patients with incremental AF burden ranged from $12,789 ± $161,749 per patient, the annual incremental patient-incurred costs in those with AF were $290 ± $4,126 per patient.
Regarding CIED type, patients with PeAF or PermAF had higher annualized adjusted costs than those with pAF. Patients in PeAF with either CRT-D or ICM had higher annualized costs than those with pAF only; however, there were no differences in adjusted annualized health care costs by AF burden category among CRT-P or ICD.
All incremental AF burden categories were associated with increased adjusted incidence rate ratios of inpatient hospitalizations, outpatient hospitalizations, emergency department visits, and clinic encounters compared to no AF (p for all < 0.001). AF-specific treatments were the highest portion of the annualized health care cost, especially for PeAF (36.4%) and PermAF (39.9%). While adverse events were higher in all AF burden categories, there was no difference in annualized cost per heart failure hospitalizations between patients with AF or without AF.
Conclusions:
The authors report that AF recognized by CIEDs is associated with significantly higher health care costs compared to patients without AF, especially in PeAF.
Perspective:
The Centers for Disease Control and Prevention estimates that 12.1 million people will have AF by 2030, which has been shown to be associated with a 4- to 5-fold increased risk of ischemic stroke and is a major cause of death and disability for other cardiac-related comorbidities. These factors greatly affect cardiovascular disease’s already growing impact on national health care expenditures. This study provides clinicians with an example of how artificial intelligence is helpful in detecting real-time arrhythmias that can correlate clinical data and corresponding medical billing and coding to reflect actual health care expenditures for specific diagnoses. Balancing the pros and cons of “incidental findings” or potential for inappropriate detections, AF CIED-detections can warrant timely diagnostic studies, consults, and interventions that if delayed, may otherwise expound overall health care utilization and costs; or it can provide objective data that support further preventative measures.
Clinical Topics: Arrhythmias and Clinical EP, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiovascular Care Team
Keywords: Atrial Fibrillation, Health Care Costs
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