Cost-effectiveness of left atrial appendage closure for stroke prevention in atrial fibrillation: a systematic review appraising the methodological quality
Authors: Hewage Sumudu , Noviyani Rini , Barnett Adrian , Parsonage William , Brain David , McPhail Steven , Sharma Pakhi , Kularatna Sanjeewa 
Published: March 2023

Background
With the predicted rise in the burden of ischemic stroke associated with atrial fibrillation (AF), implementing cost-effective interventions for stroke prevention has become increasingly important. Economic evaluations are key to making informed healthcare decisions in this context. However, the poor methodological quality of economic evaluations is a growing concern. The objective of this systematic review is to evaluate the published economic evaluations for stroke prophylaxis, focusing specifically on oral anticoagulants and the left atrial appendage closure procedure (LAAC), with a special emphasis on their methodological rigor.
Methods
Our systematic review evaluated and compared the general characteristics, model structure, and methodological quality of economic models published in electronic databases, PubMed, Medline, CINAHL, Cochrane, and Econ Lit. We assessed the methodological quality of the included studies using the modified Economic Evaluations Bias (ECOBIAS) checklist, which evaluates overall bias (part A) and model-specific bias (part B) in economic evaluations. We also evaluated conclusions by the authors on the cost-effectiveness of LAAC compared to model outputs, taking into account the methodological quality of the studies.
Results
The review included 12 studies from high-income countries that adopted either a healthcare provider or payer perspective. Our assessment revealed an overall acceptable to low methodological quality of the included studies. The cost-effectiveness analyses compared LAAC with warfarin, novel oral anticoagulants, or a combination of both. The limited availability of good quality and relevant model input data was the most discussed challenge by authors. Studies comparing LAAC with novel oral anticoagulants used indirect evaluation methods to obtain transition probabilities and effectiveness inputs for the economic model from warfarin studies due to the unavailability of trials directly comparing novel oral anticoagulants with LAAC. The most common limitations identified in the original economic evaluations were narrow perspective bias, limited sensitivity analysis bias, bias related to baseline data, bias related to treatment effects, and bias related to internal consistency. The cost-effectiveness of LAAC compared to oral anticoagulants varied across studies.
Conclusions
Our systematic review revealed a significant variation in the methodological quality of published economic evaluations comparing LAAC and oral anticoagulants, which limits the reliability of their conclusions. To ensure more reliable evidence for healthcare decision-making, we recommend using best practice guidelines and embedding economic evaluations in the design and planning stages of trials. This approach can facilitate the collection of relevant data and improve the methodological rigor of economic evaluations.