The budget impact of left atrial appendage closure compared with adjusted-dose warfarin and dabigatran etexilate for stroke prevention in atrial fibrillation

Aims Major practice changes require both clinical and economic rationale, especially where a novel device replaces an established pharmaceutical therapy. Recent studies have reported the clinical benefits of percutaneous left atrial appendage closure (LAAC) for stroke prevention in atrial fibrillation (AF) relative to standard warfarin anticoagulation, but little is published on the cost implications of LAAC. This analysis sought to quantify the budget impact of LAAC compared with warfarin and dabigatran etexilate for stroke prevention in AF. Methods and results A budget impact model was constructed from a German payer perspective across a 10-year time horizon. Clinical event probabilities were taken from the PROTECT AF and RE-LY clinical studies. Clinical events included stroke, major extracranial bleeding, systemic embolism, procedure-related complications, and death. Costs for stroke included acute, direct costs, as well as long-term disability costs. Cost inputs were taken from German inpatient diagnosis related groups (DRGs), German pharmaceutical pricing databases, and the literature. The findings from this model suggest that LAAC provides long-term clinical and economic benefit while also reducing overall mortality. At 8 years, LAAC was less expensive than dabigatran (€15 061 vs. €16 184), and at 10 years, it was only 10% more expensive than warfarin (€16 736 vs. €15 168). Conclusion The majority of LAAC costs are borne in the first year, while costs for pharmaceutical strategies continue to accrue year on year. Thus, LAAC represents an opportunity for savings to healthcare systems in the long term. This is an important consideration for payers in evaluating lifetime treatment strategies in AF.