Switching from beta-blockers to digoxin as first line therapy for heart rate control in older patients with atrial fibrillation (AF) and symptoms of heart failure could produce a cost saving of over £100m a year for the NHS, a study has found.
AF accounted for more than 1% of the annual NHS budget, predominantly from hospital admissions, researchers wrote in the journal Heart.
The RAte control Therapy Evaluation in permanent Atrial Fibrillation (RATE-AF) study was a randomised, open-label trial embedded in the NHS that directly compared low-dose digoxin – usually used as second-line therapy – with the typical first-line approach of beta-blockers.
The trial initially randomised 160 older patients with permanent AF and symptoms of heart failure (mean age 76 years, 46% women).
Researchers previously reported no difference in the primary outcome of health-related quality of life in the physical activity domain between the groups at six months, however nearly all secondary outcomes favoured digoxin by 12 months, with better patient functional capacity and less evidence of cardiac strain.
There were lower rates of side effects, cardiovascular events and hospital admissions in those randomised to digoxin.
‘Digoxin significantly less costly‘
For this prespecified health economic analysis of the National Institute for Health and Care Research-funded trial, researchers assessed information from the 149 patients who had complete data and survived to 12 months follow-up.
The analysis found no significant effect on quality-adjusted life years (QALY) between groups, however treatment with digoxin was significantly less costly than therapy with beta-blockers, with a mean saving of £530.41 per patient per year.
‘This was principally due to substantially lower rates of adverse events, with less primary and secondary healthcare utilisation compared with beta-blocker therapy,’ the researchers reported.
Extrapolating the study findings to current prevalence and costs of AF in the NHS, suggested a potential cost saving of £102 million per year, which was equivalent to a 5.9% saving on the £1.7bn spent annually on AF, the study reported.
The researchers noted the cost of secondary care services, mainly inpatient care, was significantly lower in the digoxin arm, reflecting that these patients had substantially fewer serious adverse events (16 serious adverse events in 13 patients for digoxin vs 37 in 21 patients for beta-blockers) and fewer treatment-related adverse events (29 treatment-related adverse events in 20 patients for digoxin vs 142 in 51 patients for beta-blockers).
The mean total costs for secondary care were £8.88 per patient over 12 months in the digoxin group and £484.83 per patient in the beta-blocker group, with adjusted bootstrapped difference of –£518.04 per patient in favour of digoxin.
‘While likely applicable to similar healthcare settings outside the UK, further studies with formal economic evaluation are needed to address this key evidence gap and the implications for global management of patients with AF,’ the authors concluded.
‘Safe and cost-effective treatment‘
Corresponding author Professor Sue Jowett, deputy head of the Health Economics Unit at the University of Birmingham, said the study highlighted the importance of health economic assessments and the role they could play in delivering appropriate treatments.
‘At the usual £20,000 per QALY threshold, the probability of digoxin being cost-effective compared to beta-blockers was 94%, which could lead to substantial savings if the trial results were adopted more broadly in this population,’ she said.
Trial chief investigator Professor Dipak Kotecha, professor of cardiology at the University of Birmingham, and a consultant cardiologist specialising in cardiac imaging at University Hospitals Birmingham NHS Trust, said cardiac conditions such as AF and heart failure were expected to double in prevalence over the next few decades.
‘Despite being one of the oldest drugs in use for heart disease, this study confirms an important role for digoxin in the management of these patients, providing safe and cost-effective treatment,’ he said.
Last year, the European Society of Cardiology released new guidelines at its congress in London, including one dedicated to the management of AF.
The novelties of this AF guideline included the recommendation of the new CHA2DS2-VA score to assess thromboembolic risk when making decisions on initiating oral anticoagulation, which no longer includes gender.
