Patient’s age rather than severity of the arrhythmia influences the cost of medical treatment of atrioventricular nodal or atrioventricular reciprocating tachycardia
Patient's age rather than severity of the arrhythmia influences the cost of medical treatment of atrioventricular nodal or atrioventricular reciprocating tachycardia
Michal M. Farkowski 0 1 2 4
Mariusz Pytkowski 0 1 2 4
Aleksander Maciag 0 1 2 4
Dominik Golicki 0 1 2 4
Ilona Kowalik 0 1 2 4
Marcin Czech 0 1 2 4
Piotr Rucinski 0 1 2 4
Hanna Szwed 0 1 2 4
0 Business School, Warsaw University of Technology , Warsaw , Poland
1 Department of Experimental and Clinical Pharmacology, Medical University of Warsaw , Warsaw , Poland
2 The 2nd Department of Coronary Artery Disease, Institute of Cardiology , Spartanska 1 St., 02-637 Warsaw , Poland
3 Michal M. Farkowski
4 Arion Hospitals Group , Lublin , Poland
Purpose Radiofrequency ablation (RFA) is considered the treatment of choice in cases of atrioventricular nodal reciprocating tachycardia (AVNRT) and atrioventricular reciprocating tachycardia (AVRT). Published studies suggest a considerable time gap between the onset of the arrhythmia, correct diagnosis, and RFA which may reach 10-15 years. The cost of medical treatment during that period may be substantial. The aim of the study was to calculate the annual direct medical cost of medical treatment of patients with AVNRT and AVRT and identify potential factors influencing this cost. Methods Based on the consumption of particular resources and the unit costs of services in 2013, we calculated the annual direct medical cost of care for patients with AVNRT and AVRT in Poland. We adopted the public payer's and societal perspectives. Data on health resources was collected with a structured questionnaire and medical records of patients scheduled for RFA. Additional analyses were performed to identify factors influencing this cost. Results We enrolled 82 patients: mean age 43.9 ± 14.1 years old and mean symptom duration before the RFA 13.0 ± 11.3 years. The median annual cost of medical treatment was 546 USD [312-957], 411 € [278-786], and 616 USD [369-1044], 464 € [235-721], for the public payer and the common perspective, respectively, with hospitalizations being the main cost component. In multivariate analysis, only the age of the patient significantly influenced this cost. Conclusions The annual cost of medical treatment of AVNRT or AVRT is substantial and dependent on the age of the patient rather than the severity of the arrhythmia (NCT01594814).
AVNRT; AVRT; Cost; Medical treatment
Atrioventricular nodal reciprocating tachycardia (AVNRT)
and atrioventricular reciprocating tachycardia (AVRT) are
two of supraventricular tachycardias (SVTs) which are benign
in nature in most cases but result in a significant impairment of
health-related quality of life [1–3]. In both cases,
radiofrequency ablation (RFA) is considered a curative procedure with
high effectiveness and low rate of serious complications [4–7].
While atrial fibrillation remains the main target of RFA in
many countries, SVTs remain a significant portion of RFA
procedures in Europe . The relatively non-specific clinical
p res en ta tion a nd fr eq ue nt problem s t o obt ain the
electrocardiographical (ECG) documentation of those
arrhythmias lead to a long gap between the onset of symptoms and
RFA which in many cases may exceed 15 years [5, 9, 10].
Costs of medical treatment of SVT: repetitive consultations,
hospitalizations, and diagnostic tests, due to recurrent
episodes of arrhythmias before the RFA may be substantial .
The aim of this study was to calculate the annual direct
medical cost of medical treatment of AVNRT and AVRT and
identify the factors influencing this cost.
This was a pre-specified subanalysis of the Patients’
Perspective on Radiofrequency Catheter Ablation of
AVRT and AVNRT (PPRA) Study (NCT01594814) .
PPRA was a single-center, prospective, cohort study
performed in a tertiary-care cardiological center. We enrolled
patients admitted for the RFA of AVNRT and AVRT. The
inclusion criteria were written informed consent, over
18 years of age, and sufficient knowledge of the Polish
language to independently complete the questionnaires.
The main exclusion criterion was any serious comorbidity
significantly impairing the quality of life. During the
hospitalization, eligible patients were asked to complete
questionnaires concerning general socio-economic status and
the quality of life (Patient Perception of Arrhythmia
Questionnaire, PPAQ and EQ-5D-3L) and a questionnaire
concerning health care resource utilization during the year
preceding the RFA [11–13].
Data on the following resources was collected: outpatient
specialist consultations, outpatient additional tests
(echocardiography, 24-h Holter ECG, ECG stress testing, blood
laboratory tests), acute care—emergency department visits and
sanitary transport, hospitalizations, drugs—name, and dosage.
Public insurance and private consultations and tests were
2.1 Country-specific information
Poland is a Central European country with 36 million
inhabitants and is divided into 15 voivodships, local
government units roughly equal to a county. The Polish
National Health Fund (NHF) is the single, nationwide
public insurer which covers the cost of hospitalizations,
acute care, and outpatient health care in Poland. The NHF
is divided into 15 departments, one for every voivodship.
Departments are financially independent from one another
and have similar tariffs for hospitalization (via
diagnosisrelated groups, DRG) and specialist outpatient
consultations but may differ in lump sums for acute care
providers. In terms of hospitalizations and acute care, there
are no significant private insurers but the outpatient
specialist consultations are easily commercially available
outside the NHS and the out-of-pocket costs for the patient
are reasonable. The primary care is organized as a
network of general practitioners who are recompensed by
the NHF on the basis of a lump price for every signed
patient regardless of the number of visits, type of illness,
or treatment. Similarly, emergency departments and
sanitary transport providers are paid as a lump sum based on a
projected annual number of consultations/transports rather
than actual fee-for-service.
We calculated direct medical costs of care adapting the public
payer and the common perspective of the public payer and
patient. The public payer perspective covered all costs borne
solely by the NHF. The common perspective covered all costs
borne by both the NHF and all of patients’ out-of-pocket cost
related to the arrhythmia treatment. A time horizon was
restricted to 1 year, so no discounting was applied. Costs of care
were calculated in Polish Zloty and converted to US dollars
and Euro according to the Polish National Bank mean rate of
exchange for the year 2013. Median cost of care over patients
with AVNRT or AVRT was calculated as a median cost of care
of individual patients. Calculations for all costs covered by the
Polish NHS via DRGs or cardiological specialist outpatient
care were based on unit costs derived from the NHF official
documents and resource utilization declared by patients. The
cost for in- and outpatient services was determined as the
mean cost for such services for three voivodships in 2013.
For outpatient visits, we adopted a conservative assumption
of maximizing the cost for the NHF based on additional tests
performed by the consultant. We also assumed all
hospitalization costs were calculated based on the DRG for patients with
heart arrhythmia without serious complications (DRG E62
group). The mean cost of emergency department consultation
and sanitary transport was calculated as a median cost derived
from five hospitals from three voivodships and seven
providers of sanitary transport from three voivodships. To further
increase the accuracy of the analysis, additional information
on the mean cost of emergency department consultation and
sanitary transport was calculated based on official data
obtained from the Mazovian NHF. Costs of reimbursed drugs were
calculated based on a mean yearly dose and the mean cost of
1 mg of the drug derived from the Ministry of Health’s (MoH)
official sales prices. All mentioned NHF and MoH documents
were valid for the 30th of December 2013.
Costs of specialist consultations and additional tests
performed in the private sector (patients’ out-of-pocket costs)
were calculated based on resource utilization declared by
patients and data derived from the official websites of two of the
biggest country-wide providers. Costs of non-reimbursed
drugs (patients’ out-of-pocket costs) were calculated based
on a mean yearly dose and the mean cost of 1 mg of the drug
derived from the website of a country-wide provider.
The severity of the index arrhythmia was estimated based
on the patients’ quality of life measured using the widely
recognized, generic EQ-5D-3L questionnaire . The
EQ5D-3L comprises five dimensions (mobility, self-care, usual
activities, pain/discomfort, anxiety/depression) with three
levels (problems, some problems, extreme problems) within
each dimension and a visual analog scale (VAS). The
responses for all five dimensions can be converted into a single
summary index by applying a formula that essentially attaches
values (also called weights) to each of the levels in each
dimension. The summary index equal to B1^ means no problems
at all while −0.55 means extreme problems in all five
dimensions and the worst measurable health state. In our previous
analysis, the EQ-5D-3L accurately described the quality of life
of patients with different numbers and lengths of arrhythmia
episodes and different accompanying signs and symptoms and
arrhythmia’s influence on everyday life . To take into
account all those factors and simplify the present analysis, we
decided to use the summary index of EQ-5D-3L as a single
measure of the Bseverity^ of the arrhythmia.
The study protocol was approved by the local Institutional
Review Board and was in full compliance with the
Declaration of Helsinki.
2.3 Statistical analysis
The Kolmogorov-Smirnov test was used to check for normal
distribution of continuous data. Normally distributed
continuous data were presented in terms of mean ± standard
deviation*. Non-normally distributed continuous data were
expressed in terms of percentiles (costs: median and
interquartile range) * or median, min, and max (number of
procedures) and were compared across two groups by
nonparametrical Mann-Whitney U test and across three groups
b y n on - p a r a m e t r i c a l A N O VA K r u s k a l - Wa l l i s t es t .
Categorical variables were summarized in terms of
frequencies and percentages. Multivariable linear regression analysis
was applied to verify the independent association of cost of
care in AVNRT and AVRT with predictor yields in univariate
analysis. First, we constructed a linear regression model in
which the cost of care was entered as an independent variable
(because of asymmetry >2.0, it was log-transformed) and all
potential explanatory variables from the univariate analysis
were included in the model. After, a backward selection
procedure as used with the significance set at p < 0.05 to remove a
covariate from the model. To avoid assumptions about
linearity, residuals were examined. All hypotheses were
twotailed with a 0.05 type I error. All analyses were conducted
using SAS software (version 9.2., SAS Institute Inc., NC,
Between January 2012 and August 2013, among 96
consecutive potentially eligible patients, 82 were enrolled. The
reasons for exclusion were lack of informed consent (12 patients)
and insufficient knowledge of the Polish language (2 patients).
The most important baseline characteristics of the patients
included in the analysis are presented in Table 1. Delta wave
in the surface ECG was present in 25.6 % of patients, and
13.4 % had a history of atrial fibrillation. There were no cases
of clinically significant heart failure or coronary artery
disease, and 20.7 % of patients had hypertension.
At the time of hospitalization, 26.2 % of patients were on
beta-blocker, 1.2 % on propafenone, and none on amiodarone
or sotalol. The median utility measured by EQ-5D-3L was
decreased—0.87 [0.80–1.00] as expected before the RFA of
the index arrhythmia.
The mean/median medical care resource utilization due to
arrhythmia during 1 year preceding the RFA is presented in
3.1 Cost of care
The calculated annual median cost of care over patients with
AVNRT or AVRT is presented in Table 3. The single highest
component cost of care was the cost of hospitalization—312
USD [0–312], 235 € [0–235], followed by costs of emergency
department visits—144 USD [72–288], 108 € [54–217].
Costs of drugs were relatively low and borne entirely by the
patient—14 USD [0–40], 11 € [0–30].
The cost of AVNRT calculated from the common
perspective was slightly higher than that of AVRT: 579 USD [358–
801], 496 € [318–971], vs. 459 USD [423–1289], 436 € [270–
603], p = 0.04; public payer costs were similar between
AVNRT and AVRT.
The cost of care significantly increased with age (Table 4).
The cost of care of patients living in the countryside or towns
<25,000 inhabitants were significantly higher than that of
Number of patients (%)
Mean ± SD
ECG stress test
ECG stress test
SD standard deviation, ECHO echocardiography, ECG electrocardiography, ED emergency department
patients living in bigger towns or cities: 619 USD [361–1210],
466 € [272–912], vs. 463 USD [220–647], 349 € [166–487]
(p = 0.01), and 659 USD [422–1354], 496 € [318–1020], vs.
539 USD [297–760], 406 € [223–572] (p = 0.01), for the payer
and the common perspective, respectively. Also, higher
education of the patient slightly increased the public payers’ cost
but not the cost calculated from the common perspective.
The multivariate analysis of factors influencing the median
cost of care in the univariate analysis is presented in Table 5:
only age remained a significant factor although patients with
diabetes and hypertension and patients on beta-blocker and
sotalol tended to be older. The severity of the arrhythmia
expressed as a generic quality of life was not a significant
factor in the univariate analysis and hence was not included
in the multivariable model.
The sensitivity analysis of arrhythmia cost calculation was
performed by calculating all results using lower and higher
boundaries of confidence intervals of the respective
AVNRT atrioventricular nodal reciprocating tachycardia, AVRT
atrioventricular reciprocating tachycardia, NHF National Health Fund, USD
United States dollar
component costs—the sensitivity analysis confirmed the
results of the primary analysis.
To our knowledge, this is the first study to calculate annual
costs of medical treatment of patients with AVNRT or AVRT.
While the RFA is the cornerstone of therapy for such patients,
a lengthy time between the onset of symptoms and RFA could
generate significant costs for both the health care system and
the patient alike. In our analysis, the annual cost of medical
treatment was 546 USD, 411 €, and 616 USD, 464 €, for the
public payer and the common perspective, respectively, and
the main component of this cost was hospitalization due to
arrhythmia. The cost of DRG for the catheter ablation of SVT
in Poland was about 8048 USD, 4335 €, in 2013. Median
costs were lower when we used data from the Mazovian
NHF. As mentioned before, in Poland, emergency
departments and sanitary transport providers are paid as a lump
sum based on a projected number of consultations/transports
rather than actual fee-for-service. In this case, consultations/
transports over the projected amount are not paid for at all by
the NHF and hence the lower average cost of single
consultation/transport and lower median cost of care.
Patients treated medically in the USA generated over 6000
USD of costs of care during 5 years due to 3.7 ± 1.3 clinic
visits, 17 emergency department visits, and 2 hospitalizations
. In our analysis, at least half of the patients were
hospitalized due to arrhythmia and the median number of emergency
department visits was 2 during 1 year. The easiest explanation
for the high number of hospitalization in our study is again
NHF: a patient who is hospitalized is recompensed to the
AVNRT atrioventricular nodal reciprocating tachycardia, AVRT atrioventricular reciprocating tachycardia, NHF
National Health Fund, USD United States dollar
hospital by a means of the DRG group based on the indication
and treatment received while in the emergency department
only as a lump sum regardless of the clinical situation.
Under these conditions, the hospitals are interested in
admissions rather than only the acute treatment because they get
both the compensation for DRG and emergency department
A high proportion of the median cost of care in our analysis
was due to acute situations: hospitalizations, emergency
department visits, and sanitary transport. Those costs are hard to
avoid without successful and permanent treatment of the
index arrhythmia. Medical treatment is generally considered an
accessory to the RFA which is also apparent in our study: only
about 20 % had an antiarrhythmic drug prescribed while
scheduled for RFA. As expected, median yearly cost of drugs
was low and borne entirely by the patient—about 11 €.
One of the most interesting findings of our study was that a
very important factor influencing the cost of care was the age
of the patient (Table 4). One probable explanation of this
finding is the higher proportion of additional tests to exclude
concomitant diseases especially coronary artery disease (CAD) in
older patients since chest discomfort and dyspnea
accompanying arrhythmia may mimic CAD. In our previous analysis,
men were more likely to undergo echocardiography and stress
testing mainly to exclude significant CAD . This is
important since older patients with AVNRT are not uncommon .
Other possible explanation is that our study group was too
small to highlight the importance of higher prevalence of
comorbidities in this group and their independent influence.
Other obvious factors such as symptom duration before the
RFA and arrhythmia severity measured as a quality of life
(EQ-5D-3L) did not affect the cost of medical treatment of
AVNRT or AVRT.
The annual cost of medical treatment of AVNRT or AVRT
was significantly lower than the average annual cost of heart
failure or CAD treatment in Poland: 1787 € and 2254 €,
respectively [15, 16]. In both cases, the cost depended heavily
on the severity of the disease measured as a New York Heart
Association or Canadian Cardiovascular Society classification
and hospitalizations being the main cost component.
Surprisingly, in our analysis, severity of the arrhythmia was
not associated with cost of care but hospitalizations remained
the main cost component. An estimated cost of atrial
fibrillation treatment, 1010 €, in the Polish setting was again higher
than that in AVNRT or AVRT with hospitalizations among the
main drivers of costs .
This study has its limitations, the most important being the
medium sample size and its single-center character, both
limiting the generalizability of study findings. We tried to limit
the potential selection bias by enrolling a wide range of
patients with different socio-economic status and severities of
the arrhythmias. All calculations were performed based on
an assumption of maximizing health care providers’ income;
hence, presented costs for the public payer might have been
slightly overestimated. On the other hand, we did not incur
costs of the primary care which in Poland are borne as a lump
sum regardless of the disease and treatment so were not
The data on utilized health resources was gathered up to
1 year prior to the RFA to minimize the potential recall bias.
During the pilot phase of PPRA, it appeared that patients had
significant problems with recalling information on outpatient
visits or acute treatment over longer periods than about 1 year.
By omitting data from longer periods of time, we limited the
generalizability and it is hard to reliably estimate the potential
influence of this kind of data on the results of the study.
The annual cost of medical treatment of AVNRT or AVRT is
substantial and dependent mainly on the age of the patient.
Bearing in mind study limitations and issues concerning
international generalizability of economic analyses, this study
suggests that early diagnosis and definitive treatment of AVNRT
or AVRT in younger patients may lower costs of treatment of
those arrhythmias and alleviate the economic burden on local
health care payers.
Acknowledgments The authors would like to thank Mr. Slawomir
Adam Tarka, M.D., Ph.D., for the invaluable help in obtaining the data
from the Mazovian National Health Fund.
Compliance with ethical standards The study protocol was approved
by the local Institutional Review Board and was in full compliance with
the Declaration of Helsinki.
Source of funding The study received support from the Institute of
Cardiology, Warsaw, Poland, research grant 2.16/IV/12.
Conflict of interest
The authors declare that they have no conflict of
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