Few policy topics in cardiology have been argued as much as the question of whether clinicians should screen for asymptomatic or paroxysmal Afib. Undoubtedly, diagnosing Afib earlier rather than later is better, as the condition increases stroke risk by five times, and interventions using oral anticoagulants can reduce that risk by 65%, according to the European Heart Journal.
Yet screening recommendations in general populations must account for other factors beyond outcomes alone, from patient anxiety and feasibility to healthcare costs. With the confluence of these many factors, the question of whether or not to screen patients becomes more complicated than whether or not early detection saves lives.
In 2018, the US Preventive Services Task Force (USPSTF) acknowledged the difficult balance of factors in a final recommendation statement saying there was insufficient evidence to recommend widespread Afib screening via ECG. Importantly, however, the USPSTF did not consider the costs or cost-effectiveness of providing ECGs in its recommendation statement. It only factored in the benefits and harms of screening, the effectiveness of screening, and the benefits and harms of Afib interventions.
So would the potential cost-effectiveness of Afib screening tip the scales and make screening programs more worthy of policies and clinical guidance, particularly in the COVID-19 era? That question is still being explored, but promising evidence indicates that it might.
Afib Screening and Downstream Healthcare Costs
As authors in the European Heart Journal note, costs associated with Afib make up about 2% of the total healthcare spending in high-income countries, and that number may well grow in the future with Afib incidence. Between 2010 and 2050, the number of people diagnosed with Afib is projected to double, from 33 million to potentially 66 million people worldwide.
Given the risks of stroke associated with Afib—and the fact that 1 in 10 patients with stroke also receive a first-time Afib diagnosis upon hospitalization—it's not unreasonable to assume that more detection could help curb the risk of stroke by providing the basis for increased prescription of anticoagulant therapies.
One simulation model published in EP Europace supports that assumption. Comparing the cost-effectiveness of Afib screening among 75-year-old asymptomatic patients, the model found that screening could avert 8 strokes per 1,000 people at a cost of €6,583 (approximately $8,100) per avoided stroke.
That model helped to inform a systematic review from the UK's National Institute for Health Research (NIHR). Using data from the EP Europace study and others, the NIHR demonstrated the cost-effectiveness of a hypothetical screening effort that would check patients starting at age 65, and every five years thereafter, for signs of Afib using nurse pulse palpitation or modified blood pressure monitors confirmed by 12-lead ECGs.
With an annual burden of $46 billion in the United States, according to the Centers for Disease Control and Prevention, stroke represents a significant financial cost, not just for patients and providers across the healthcare continuum but also for people outside of healthcare, including employers due to missed days of work. Even a modest decrease in stroke rates could reduce these expenses substantially.
And yet, stroke is not the only costly complication associated with Afib. As one non-valvular Afib model in Applied Health Economics and Health Policy notes, other clinical events tied to Afib include embolism, myocardial infarction, and bleeds. Across all of these conditions, authors found Afib screening in people 75 or older to be cost-effective at a willingness-to-pay threshold of $100,000 per quality-of-life-year gained.
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Limitations of Widespread Afib Screening
It's important to note that many of the assumptions related to cost-effectiveness of Afib screening have limitations. On one hand, patient adherence is a challenge: authors in the Journal of Geriatric Cardiology report that up to 39% of patients who are prescribed anticoagulants fail to comply with their treatment plans within the first 15 months of therapy. To bolster compliance, clinicians should be diligent with patients about the importance of medications and help them identify and reduce barriers, including costs.
Additionally, there's a particular dearth of randomized controlled trials examining the effectiveness of widespread advanced Afib screening—as Patrick Moran, Senior Research Fellow in Health Economics at Trinity College Dublin, notes in a BMJ Head to Head article and audio debate.
Proven Cost Savings of Opportunistic Screening
These limitations in RCT evidence do not mean that providers shouldn't screen for Afib in high-risk individuals such as older patients, particularly in the ambulatory setting with ECGs. After all, questions of healthcare policy can often be at odds with questions of individual decision-making, and it takes more effort and resources to launch a national screening effort than it does to promote screening at practices with enough resources.
Additionally, studies in Europace, Circulation, PLOS Medicine, and elsewhere have noted the cost-effectiveness and utility of screening for Afib opportunistically—such as screening older individuals during routine events like a flu vaccination, an echocardiogram, or a regular hospital visit—rather than in a broadscale fashion.
In these instances, bedside ambulatory ECG can be an inexpensive and crucial part of the diagnostic pathway, helping to inform prompt and thorough care for at-risk patients and making Afib screening more feasible in more settings. Wearable ECGs are another trend that may make Afib surveillance more attainable for patients and providers in 2021 and beyond.
We may be a long way off from a national recommendation for widespread Afib screening, but if one ever comes, a 2015 editorial from Circulation said it best: for mass screening to work, it has to work cost-effectively. Fortunately, it appears to have the potential to do so.