OBJECTIVES: Documentation of atrial fibrillation (AF) is required to initiate oral anticoagulation therapy for recurrent stroke prevention. The cause of ischemic stroke remains uncertain despite a complete diagnostic evaluation in 20-40% of cases (cryptogenic stroke), and conventional standard of care (SoC) often fails to diagnose AF. An insertable cardiac monitor (ICM) is a diagnostic device which has been shown to improve detection of AF in this patient population. We evaluated the cost-effectiveness of ICM versus SoC, in patients with a cryptogenic stroke, from a Dutch payer perspective.

METHODS: A lifetime Markov model was developed to assign patients to health states according to the presence and detection of AF, the occurrence of cerebrovascular and bleeding events, and death. Utilities and costs were applied to each state according to occurrence of stroke, AF diagnosis and drug therapy use. The model used 3-month cycle length for state transitions and a lifetime horizon. Costs and QALYs were discounted at 4% and 1.5% per year, respectively. Probabilistic sensitivity analysis was undertaken to explore the effect of parameter uncertainty.

RESULTS: In the base-case analysis, the model predicted an incremental cost-effectiveness ratio (ICER) of €24,715 per QALY gained. Amongst the CHADS2 sub-group analyses, the ICER ranged from €22,011 (CHADS2 score 4 to 6) to €29,795 (CHADS2 score 2). Probabilistic sensitivity analysis suggested that ICM had a probability of 91% of being cost-effective at a threshold of €80,000 per QALY gained.

CONCLUSIONS: The results suggest that ICM is a cost-effective intervention in patients following cryptogenic stroke, leading to improved health outcomes at acceptable additional cost via improved detection of AF and subsequent strokes avoided. The ICER was within the cost-effectiveness threshold used in the Netherlands and the probabilistic analysis showed a high probability of cost-effectiveness, indicating that the model is robust to variability in the input parameters.