Digoxin benefits surpass beta-blockers for older AF patients and the NHS, study finds

6th February 2025

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.

Prostate cancer screening with MRI after PSA a cost-effective strategy

21st November 2022

Prostate cancer screening that involves an MRI scan following a PSA test and then targeted biopsies was shown to be a cost-effective approach

A prostate cancer screening strategy that involves an MRI scan following a prostate specific antigen (PSA) test with subsequent targeted biopsies, is a more cost-effective strategy than using just a PSA and standard biopsy according to a cost-effectiveness analysis by Swedish researchers.

Prostate cancer (PCa) screening based on PSA, has been shown in a 16-year follow-up study, to reduce prostate cancer mortality. A biopsy is normally used to confirm the diagnosis of PCa though in recent years there has been an increase in the role of magnetic resonance imaging (MRI) as an alternative means for the identification of PCa. In fact, data suggests that the use of multi-parametric magnetic resonance imaging (MP-MRI) might allow 27% of patients to avoid a primary biopsy. In a 2021 study which compared MRI-targeted or standard biopsy for the purposes of screening for PCa, it was found that in men with a PSA level > 3 ng/ml, an MRI result suggestive of prostate cancer was non-inferior to standard biopsy for detecting clinically significant prostate cancer. In the trial, men were randomised to either a 10 to 12-core standard biopsy or to undergo a triage MRI and then a standard biopsy if the MRI results suggested prostate cancer. Given the non-inferior findings of this study, the Swedish team set out to determine the cost-effectiveness of the MRI-based screening approach in men aged 55 to 69 years of age.

The researchers modelled three scenarios: no screening (strategy 1); PSA and standard biopsy every four years (strategy 2) and finally, MRI following an elevated PSA and then a standard biopsy if the men had a PI-RADS value of between 3 and 5, i.e., which is suggestive of PCa. For each of the three strategies, the team modelled several different outcomes including the mean lifetime number of screening tests, MRIs, over-diagnosis (where screening was positive but would not have presented with symptoms before death due to other causes) and deaths. The incremental cost-effectiveness ratio (ICER), which represents the additional cost of one unit of outcome gained by one strategy compared with another, was calculated for each scenario. The ICER was calculated by dividing the difference in costs by the difference in quality-adjusted life-years (QALYs) for the no screening and the two alternative strategies.

Prostate cancer screening and cost-effectiveness

A total of 603 men were randomised to the standard arm and 929 to the MRI arm and of whom, 11.9% underwent MRI or any biopsy.

When compared against a strategy of no screening, the ICER for the MRI and combined biopsies was $53,736 per QALY gained compared to $69,254 for the PSA and standard biopsy strategy and which the authors designated as a moderate cost per QALY gain. Furthermore, MRI-based screening reduced the number of lifetime biopsies and over-diagnosis by approximately 50% and had a high probability of being cost-effective compared to the alternative strategies.

The authors concluded that a strategy for prostate cancer screening based on PSA followed by MRI with subsequent combined targeted and standard biopsies, had a high probability to be more cost-effective compared with the traditional screening pathway using PSA and a standard biopsy.

Citation
Hao S et al. Cost-effectiveness of Prostate Cancer Screening Using Magnetic Resonance Imaging or Standard Biopsy Based on the STHLM3-MRI Study. JAMA Oncol 2022

World Obesity Day 2022: Study explores potential of bariatric surgery in preventing COVID-19 deaths in severe obesity

4th March 2022

Clinical evidence has revealed that bariatric surgery could prevent COVID-19 deaths in people living with obesity, a group that has been disproportionately affected during the pandemic. 

The study comes at a time when the NHS continues to be under severe pressure from COVID-19. The findings are part of a study, ‘Cost-effectiveness of bariatric and metabolic surgery, and implications of COVID-19 in the United Kingdom, co-authored by Dimitri Pournaras, a specialist in Upper Gastrointestinal, Bariatric, and Metabolic Surgery and funded by Johnson & Johnson Medical Devices Companies.

It explored the possible clinical and economic benefits of bariatric surgery compared with nonsurgical treatment options, considering the broader impact of COVID-19 on people living with obesity. The research team concluded that increased provision of bariatric surgery could reduce COVID-19-related morbidity and mortality, along with obesity-related comorbidities, ultimately reducing the clinical and economic burden of obesity. 

Among 1000 individuals with body mass index (BMI) ≥ 40 kg/m2 or BMI ≥ 35 kg/m2 with obesity-related comorbidities, bariatric surgery would prevent 117 deaths due to COVID-19 alone. Looking at the impact on hospital usage in the same group and assuming that they would all get COVID-19, 124 people would not be admitted to the hospital and 161 would not be admitted to the intensive care unit.

Delaying bariatric surgery by five years further increased costs and had a negative impact on quality of life, compared with not delaying treatment.

Mr. Pournaras stated: “These striking figures are only focusing on outcomes associated with the pandemic. The benefits of bariatric surgery with sustained weight loss maintenance will have a persistent effect on improving survival, reducing the burden of obesity-associated disease and improving functional outcomes for the individuals who have received this type of treatment.

With the pandemic set to continue for the foreseeable future, the effective treatment of obesity should be a societal responsibility that we tackle together. Not just to ease the burden on the NHS, but to optimise outcomes for people living with obesity.” 

Sarah Le Brocq, obesity advocate and key stakeholder across several obesity groups – including sitting on the strategic council for the All-Party Parliamentary Group on Obesity – said: “People living with obesity are genuinely fearful of contracting COVID-19, amid a growing number of reports that they are at greater risk of dying. We clearly need to introduce measures that tackle this, both in terms of reducing the risk to patients and the probable impact of them in the long-term.”