Ann Thorac Surg 2007;83:1713-1716
© 2007 The Society of Thoracic Surgeons
Original Articles: Cardiovascular
Health Care Consumption Due to Atrial Fibrillation is Markedly Reduced by Maze III Surgery
Per Wierup, MD, PhD*,
Hans Lidén, MD,
Birgitta Johansson, MD,
Michael Nilsson, CEO,
Nils Edvardsson, MD, PhD,
Eva W.-O. Berglin, MD, PhD
Cardiovascular Division, Sahlgrenska University Hospital, Gothenburg, Sweden
Accepted for publication December 21, 2006.
* Address correspondence to Dr Wierup, Department of Cardiothoracic Surgery, Aarhus University Hospital, Skejby Brendstrupgårdsvej, 8200 Aarhus N, Denmark (Email: pwi{at}sks.aaa.dk).
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Abstract
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Background: Health care consumption and costs for the treatment of atrial fibrillation are high. Atrial fibrillation is effectively treated by the surgical Maze III procedure according to the Cox method. We describe the effects of this procedure on health care consumption and economy.
Methods: From October 1997 through March 2002, 72 patients underwent the Maze III procedure. Medical records of these patients were reviewed, and all data regarding hospitalization and outpatient clinic visits for atrial fibrillation and its related diseases were recorded. Accounting divisions from the contributing hospitals were consulted for the exact cost of each of these services, which were allocated into preoperative, perioperative, and postoperative periods.
Results: The perioperative mortality was zero. Long-term freedom from symptomatic atrial fibrillation was verified in 96% of the patients. The number of hospitalization days decreased by 84%, from 471 during the preoperative period to 79 in the postoperative (p < 0.001), and costs during the same periods decreased by 75%, from 7,075,000 Swedish Kronor to 1,757,000 Swedish Kronor (p < 0.001).
Conclusions: The Maze III procedure significantly decreased the postoperative hospitalization costs in patients undergoing surgery primarily for atrial fibrillation. As well as providing an effective treatment for symptomatic arrhythmia, this procedure breaks the undesirable trend of increasing health care consumption resulting from treatment of atrial fibrillation.
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Introduction
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Atrial fibrillation (AF) is a frequent disorder with clinically important consequences: symptomatic tachyarrhythmia, impaired hemodynamic function due to loss of the atrial kick, and an increased risk of emboli from left atrial thrombi [1]. Persistent or permanent AF is associated with a doubling of mortality from cardiovascular disease [2], and after adjusting for coexisting cardiovascular conditions, AF remains an important incremental risk factor for death [3, 4]. Patients with lone AF have a fivefold to sevenfold increase in the risk of stroke [5]. In addition to its contribution to patient suffering, this chronic and progressive disease represents a significant burden on the health care economy. A recent study from the United Kingdom showed that the direct yearly cost of AF was £459 million [6].
At our institution, highly symptomatic patients with drug-resistant AF have access to the surgical Maze III procedure according to the method of Cox, which is the most efficient technique in restoring sinus rhythm [7–9], thereby preventing stroke [10]. The influence of this procedure on health care costs has not yet been studied. Hence, the aim of this paper was to evaluate the impact of the Maze III procedure on the health economy.
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Patients and Methods
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Definitions
The classification of AF was made retrospectively according to the joint American College of Cardiology/American Heart Association/European Society of Cardiology Task Force [11]. Thus, if a patient had two or more episodes, the AF was considered recurrent; and recurrent AF was further subclassified as paroxysmal, persistent, or permanent. Paroxysmal AF was defined as AF that lasts 7 days or less and terminates spontaneously. Persistent AF does not terminate spontaneously, but requires electrical or pharmacologic cardioversion. Permanent AF was defined as a condition in which sinus rhythm cannot be restored by cardioversion, or the patient and physician have decided against further efforts to achieve sinus rhythm.
Patients and Surgical Procedures
This retrospective study was approved by the Ethics Committee at Gothenburg University (reference number s75403). All included patients gave their informed written consent. Seventy-two consecutive patients who underwent the classic cut-and-sew Maze III procedure of the Cox method [12] from October 1997 through March 2002 constituted the study population. The procedure was performed without modification and with no adjunctive energy sources other than the standard cryolesions to the tricuspid and mitral annulus. All procedures were performed at the Sahlgrenska University Hospital, Gothenburg. The indications for surgery were intolerable symptoms of AF due to intolerance or inefficacy of pharmacologic therapy or cerebral embolism. Patients were eligible for the study if they had been followed for a minimum of 2.5 years after the operation.
Preoperative characteristics are outlined in Table 1. Atrial fibrillation was the primary reason for surgery in all patients. During preoperative assessment, additional, asymptomatic, and in most cases, previously undiagnosed conditions were found in 24% of the patients that merited concomitant surgical procedures (Table 1). Pacemakers previously implanted owing to antiarrhythmic drug-induced bradycardia were explanted in 5 patients during surgery as antiarrhythmic medication was no longer judged necessary. Perioperative arrhythmias were managed with sotalol and direct current (DC) conversions as necessary. Amiodarone was not used. The patients received coumadin postoperatively according to current guidelines. All patients were thoroughly instructed to immediately contact their local hospital if they should experience any irregular heart rhythm. Follow-up consisted of a query regarding symptoms of arrhythmia, quality of life, and 12-lead electrocardiogram at 6 months and 30 months after surgery. Follow-up was 100% complete.
Health Economy
Medical records were thoroughly reviewed, and all data regarding hospitalization and outpatient clinic visits for AF and its related diseases and treatments (arrhythmia, tachycardia, dyspnea, tachycardia-induced heart failure, transient ischemic attach, stroke, DC conversion, pacemakerimplantation, and medication) were recorded. Visits or hospitalization for any other cause were excluded. The accounting divisions of the 14 referring hospitals in southwest Sweden were consulted for the exact cost of each of these services. All required data could be obtained for all patients.
The medical costs for three time periods were analyzed: a preoperative period consisting of the 2 years immediately before the Maze III procedure; a perioperative period including the preoperative investigation, surgery, and the first 6 postoperative months; and a postoperative period from the seventh month after surgery through the end of the follow-up after 30 months. During the first months after surgery, there is a shortened refractory period in the atria with subsequent microreentrant tachycardias. Thus, full antiarrhythmic affect of the procedure cannot be expected until after 6 months. For this reason, the postoperative evaluation period was chosen to start with the seventh postoperative month.
Statistical Analysis
Hospitalization days and hospital costs before and after surgery were compared using the Wilcoxon signed ranked test for paired observations.
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Results
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Medical Results
The 30-day mortality was zero. There was no perioperative stroke, myocardial infarction, or need for intra-aortic balloon pump. Additional perioperative data are shown in Table 2. Freedom from symptomatic AF 2.5 years postoperatively was 96%, and subsequent electrocardiography showed sinus rhythm in 89% and atrially paced rhythm in 7%. Episodes of asymptomatic AF that were noted neither by the patients nor their doctors could not be recorded in this retrospective analysis. There were no mortality, cerebrovascular, or systemic embolic events during the follow-up. The need for DC cardioversions for AF was dramatically reduced in the postoperative as compared with the preoperative period (Fig 1). Five patients who did not have pacemaker preoperatively had a pacemaker implantation postoperatively because of sick sinus syndrome not detectable before surgery.
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Fig 1. Total number of direct current conversions performed in all patients 2 years before (y pre-op) and 2 years after (y post-op) Maze III surgery for atrial fibrillation.
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Hospitalization Days
The number of hospitalization days decreased by 84%, from 471 (all patients) during the preoperative period to 79 (all patients) in the postoperative period (p < 0.001; Fig 2).
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Fig 2. Mean number (± SEM) of hospitalization days per patient and time period, 2 years before (y pre-op) and 2 years after (y post-op) Maze III surgery for atrial fibrillation.
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Hospital Costs
The hospital costs for the treatment of AF and its related diseases in this population decreased by 75%, from 7.08 million Swedish Kronor (SEK [all patients]) during the preoperative period to 1.76 million SEK (all patients) in the postoperative period (p < 0.001). The total cost for the perioperative period was 20.6 million SEK (all patients). See Table 3
for an itemization of the costs for the different periods.
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Comment
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In 1998, Wolf and colleagues [13] published a prospective American cohort study comparing Medicare patients hospitalized because of AF and one other cardiovascular diagnosis with a matched group of patients without AF. The cumulative Medicare spending was as much as 22% higher for AF patients. Considering that approximately 2.3 million adults in the United States currently have AF [14], it is easy to conclude that AF is a costly public health problem.
The Cox Maze III procedure is not a commonly practiced procedure, but those who perform it have reported consistent and excellent results [7–10]. Those studies are concurrant with the findings of this retrospective study, in which 96% freedom from symptomatic AF and a 98% reduction in the need for DC cardioversions were observed postoperatively. Perhaps equally impressive in the present study, the Maze III procedure resulted in decreases of 84% (p < 0.001) in number of hospitalization days and 75% in costs (p < 0.001) of treating patients with AF during the postoperative period compared with the preoperative period. These results were consistent even after a further analysis in which patients who underwent concomitant procedures were excluded. The Maze III procedure was accomplished without mortality and with a minimum of adverse events. As with all interventions, there is a relatively high initial cost related to the surgical procedure. In our institutions, however, the surgical costs are greatly offset by the decreases in future costs due to treatment of AF and time that the patient is absent from work. Given these patients’ comparatively young age and expected survival, which is 29 years for this group, the expected life-time cost benefit with this procedure is 784,000 SEK for each patient, with the full perioperative cost taken into account. One should also keep in mind the fivefold to sevenfold increase in the risk of stroke [5] for these patients if they do not undergo operation.
The cost of treatment varies from one geographic region to another, depending on the availability of treatment modalities, compliance with existing guidelines, and cost of pharmacologic and nonpharmacologic alternatives. A uniform preoperative regimen for AF did not exist between the 14 referring hospitals; however, the indications for assessment and surgery were strictly followed by the assessing electrophysiologist and operating surgeon at Sahlgrenska University Hospital. The main message of our retrospective study should therefore be interpreted as the comparison of health care consumption and costs after recovery from successful Maze III surgery relative to the preoperative health care consumption and costs.
Many additional benefits from performing the Maze III procedure on patients with AF may not be apparent until the benefits of restoring and maintaining sinus rhythm can be shown as reductions in stroke, heart failure, and other long-term consequences of AF. This means that a particular care provider will pay the costs for the treatment, while the same provider may not balance these costs against later benefits for society. The present conservative health care economy favors efforts showing short-term benefits that can be immediately visible in a budget, whereas longer term benefits for the society have been difficult to use as an incentive for increased use of a particular treatment. However, even if only considering short-term benefits, the Maze III procedure is an effective therapy with excellent efficacy in terms of symptom reduction and reduction of morbidity and, hence, reduced health consumption.
Limitations
The natural clinical course of AF is variable but usually progressive [3, 11, 13–15]. No population study has described spontaneous regression of AF. Our economics analysis did not include the costs for drug prescriptions. However, since the average use of antiarrhythmic drugs and coumadin have decreased postoperatively by 93%, it is likely that these costs have decreased as well. Because we first started with the Maze III procedure in October 1997, evaluation periods were chosen to achieve a balance between a representatively long follow-up and the inclusion of a large patient population in this retrospective analysis. Because we did not perform continous Holter monitoring during the follow-up period, we can not exclude the possibility that some patients had episodes of nonsymptomatic AF. However, the aim of this paper was to evaluate the impact of the Maze III procedure on the health care consumption and economy.
In conclusion, the economic burden imposed on society by AF is great and is increasing. For patients treated with the Cox Maze III procedure, there is a significant and considerable reduction in both postoperative health care consumption and cost of care for AF. This procedure is a good option for severely symptomatic AF patients.
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References
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Abstract
Introduction
