213 Expanding left atrial appendage occlusion (LAAO) in England: modelling the impact of low national adoption

Introduction Stroke prevention is a key ambition of the NHS Long Term Plan.¹ Catheter-based LAAO has been shown to provide a safe and effective alternative to oral anticoagulants (OAC), resulting in comparable stroke prevention and lower rates of major bleeding,² in patients with non-valvular atrial fibrillation (NVAF) not treated with OACs. In England, commissioning policy allows LAAO in OAC contraindicated NVAF patients in a limited number of centres. Annual procedures were predicted to reach 1,000 by 2023. However, these currently total approximately 270 (<5 LAAO per million inhabitants, vs around 30 in France, Italy and Spain, and 73 in Germany),³ thus leaving most eligible patients non-optimally protected from stroke. This analysis quantifies the impact of extending LAAO adoption in England. Methods We constructed a budget impact model from the perspective of the NHS, exploring the 10 year impact of increasing LAAO penetration over three years in a pool of NVAF patients with CHA2DS2-VASc score ≥2 not suitable for OAC therapy. A total of 53,598 eligible patients were predicted using QOF data. The model investigates 3 scenarios by quantifying the impact of treating 1,000 patients each year (scenario 1), 10% of eligible patients (scenario 2) and all eligible patients (scenario 3) per year in years 1–3 vs baseline (current procedure number). The Pinnacle FLX trial informed clinical event rates and post-procedural drug regimen for LAAO, and the comparator arm used data from a large AF cohort study,⁴ matched by CHA2DS2-VASc and HAS-BLED score. All-cause mortality was accounted for. Long term adverse events included ischaemic stroke (1.43% vs 5.57% annually) split between disabling and non-disabling, and major bleeding (5.35% vs 3.81%). Costs were taken from inpatient Healthcare Resource Groups, literature and the NHS Drug Tariff. Results The model showed significant 10 year cost savings and avoidance of strokes (table 1), with a net positive budget impact observed at year 5 (figure 1). Conclusions LAAO expansion in the population of interest produces significant long-term benefits. Stroke avoidance remains an essential clinical priority(1) given its significant impact on quality of life and healthcare and social costs. The initial investment in LAAO procedure and device is offset after 5 years, driven by the reduced cost burden of stroke. Reaching the NHS target of 1,000 LAAO patients per year would result in avoidance of 734 strokes and savings of £37 million in long-term stroke cost over 10 years; benefits would grow even larger if 10% of eligible patients received LAAO. Given the current low penetration of LAAO in England, therapy expansion would require addressing challenges related to capacity, referral pathways and distribution of centres. References NHS England. NHS Long Term Plan 2019 https://www.longtermplan.nhs.uk/ Reddy VY, Doshi SK, Kar S, et al. 5-year outcomes after left atrial appendage closure: from the PREVAIL and PROTECT AF trials. J Am Coll Cardiol. 2017;70(24):2964–2975. doi:10.1016/j.jacc.2017.10.021 Based on Hospital Episode Statistic data (England), Programme de médicalisation des systèmes d'information (France), Società Italiana di Cardiologia Interventistica (GISE, Italy), Spanish Cardiac Catheterization and Coronary Intervention Registry (p, Institut für das Entgeltsystem im Krankenhaus (InEK, Germany) for LAAO procedures data; and on the UK Office for National Statistics and the World Bank for population data. Friberg L, Rosenqvist M, Lip GY. Evaluation of risk stratification schemes for ischaemic stroke and bleeding in 182 678 patients with atrial fibrillation: the Swedish Atrial Fibrillation cohort study. Eur Heart J. 2012;33(12):1500–1510. doi:10.1093/eurheartj/ehr488 Conflict of Interest Consultation fees for BMS-Pfizer, Daiichi-Sankyo, Bayer, Boehringer Ingelheim, Abbott, Boston Scientific, Biosense Webster, Aurigen Medical, Atricure,