How does the Cox maze procedure compare? Cost-effectiveness analysis of alternative treatments of atrial fibrillation.

Objectives: Data related to the cost effectiveness of surgical interventions and catheter ablation is sparse. This model-based analysis assessed the clinical and economic trade-offs involved in using catheter ablation or the Cox maze procedure in treating patients with atrial fibrillation. Methods: A deterministic model was developed to project 1 year and lifetime health-related outcomes, costs, quality-adjusted life years (QALYs) and cost effectiveness of each treatment in patients with atrial fibrillation. Using previously unpublished Inova Heart and Vascular Institute (IHVI) data for patients undergoing either procedure, 1 year cost and clinical efficacy inputs were estimated. This data was supplemented with published literature and used to estimate costs, utilities, mortality and likelihood of patient improvement. Results were reported as cost-effectiveness ratios in $/QALY. Sensitivity analyses were conducted to assess the robustness of results. Results: Patients initially treated with a Cox maze procedure were estimated to have higher costs than those treated with catheter ablation, both after 1 year and over the lifetime. However, patients undergoing the Cox maze procedure also had lower rates of 1 year mortality than catheter ablation patients (3.5% vs. 8.5%) and the highest rate of improvement following treatment, resulting in higher QALYs (12.4 vs. 10.2). Compared to catheter ablation, the lifetime incremental cost-effectiveness ratio for the Cox maze surgical procedure was $12,794 per QALY gained. Without quality adjustment, the ratio was $11,315. Results were most sensitive to the likelihood of improvement following each intervention and the cost of the initial procedure. Conclusions: At a societal willingness to pay of $100,000/QALY, Cox maze procedure was found to both increase overall and quality-adjusted survival and constitute an effective use of resources in patients with atrial fibrillation.