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Both NOACs and LAA closure (LAAC) with the Watchman device (Boston Scientific, Marlborough, MA) have advantages over warfarin for AF stroke prevention. However, their impact on healthcare costs, which are increasingly being shifted from payers to patients, must also be evaluated. This analysis assessed the budget impact of these stroke prevention therapies both to Medicare and to Medicare beneficiaries (patients).
A budget impact model was developed from both Medicare and patient perspectives assessing costs at 5 and 10 years. LAAC inputs were taken from pooled PROTECT AF 5-year and PREVAIL 3-year data, and warfarin and NOAC inputs were from published meta-analyses. The model captured therapy costs and complication costs, including procedural complications and follow-up strokes and bleeds. Stroke costs included acute care and long-term disability. Medicare costs were from 2017 DRG and CMG rates. 2017 Medicare deductibles and coinsurance rates were used for the patient analysis.
At 5 years, LAAC Medicare costs ($21,577) were lower than NOAC costs ($23,269) but higher than warfarin ($10,034). At $3,871, LAAC was the lowest cost therapy for patients at 5 years, being lower than NOACs by 63% and warfarin by 42%. At 10 years, LAAC was least costly to Medicare and patients ($34,097), with combined costs being 15% lower than warfarin and 48% lower than NOACs. Complications comprised 41% and 30% of LAAC and NOAC overall costs, compared to 83% for warfarin.
|5-year results / 10-year results|
|Medicare||Therapy||$17,065 / $17,308||$1,506 / $2,573||$18,127 / $31,396|
|Complications||$4,512 / $9,706||$8,528 / $21,737||$5,142 / $13,455|
|Total||$21,577 / $27,014||$10,034 / $24,310||$23,269 / $44,851|
|Patient||Therapy||$1,890 / $2,290||$2,480 / $4,236||$8,195 / $14,195|
|Complications||$1,981 / $4,793||$4,164 / $11,601||$2,134 / $6,469|
|Total||$3,871 / $7,083||$6,644 / $15,837||$10,329 / $20,664|
|Overall Total||$25,448 / $34,097||$16,678 / $40,147||$33,598 / $65,515|
LAAC yielded the lowest costs to patients by year 5 and to Medicare by year 10. Warfarin total costs were driven by spending on complications, which likely represent an unplanned financial burden for patients. LAAC with Watchman yields substantial savings to Medicare and patients.
STRUCTURAL: Left Atrial Appendage Exclusion