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Feasibility and cost-effectiveness of stroke prevention through community screening for atrial fibrillation using iPhone ECG in pharmacies

Journal: Thrombosis and Haemostasis
ISSN: 0340-6245
DOI: https://doi.org/10.1160/TH14-03-0231
Issue: 2014: 111/6 (June) pp. 1007–1199
Pages: 1167-1176

Feasibility and cost-effectiveness of stroke prevention through community screening for atrial fibrillation using iPhone ECG in pharmacies

The SEARCH-AF study

Online Supplementary Material

See also Editorial by Potpara, Lane

N. Lowres (1, 2, 3), L. Neubeck (4, 5), G. Salkeld (6), I. Krass (7), A. J. McLachlan (7, 8), J. Redfern (3, 4), A. A. Bennett (7, 8), T. Briffa (9), A. Bauman (6), C. Martinez (10), C. Wallenhorst (10), J. K. Lau (1), D. B. Brieger (1, 2, 3), R. W. Sy (1, 2, 3), S. B. Freedman (1, 2, 3)

(1) Cardiology Department, Concord Repatriation General Hospital, University of Sydney, Sydney, New South Wales, Australia; (2) Anzac Research Institute, Sydney, New South Wales, Australia; (3) Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia; (4) The George Institute for Global Health, Sydney, New South Wales, Australia; (5) Sydney Nursing School, University of Sydney, Sydney, New South Wales, Australia; (6) School of Public Health, University of Sydney, Sydney, New South Wales, Australia; (7) Faculty of Pharmacy, University of Sydney, Sydney, New South Wales, Australia; (8) Centre for Education and Research on Aging, Concord Repatriation General Hospital, Sydney, New South Wales, Australia; (9) School of Population Health, University of Western Australia, Perth, Western Australia, Australia; (10) Institute for Epidemiology, Statistics and Informatics GmbH, Frankfurt, Germany

Keywords

Screening, Atrial fibrillation, cost-effectiveness, anticoagulation, stroke prevention

Summary

Atrial fibrillation (AF) causes a third of all strokes, but often goes undetected before stroke. Identification of unknown AF in the community and subsequent anti-thrombotic treatment could reduce stroke burden. We investigated community screening for unknown AF using an iPhone electrocardiogram (iECG) in pharmacies, and determined the cost-effectiveness of this strategy.Pharmacists performedpulse palpation and iECG recordings, with cardiologist iECG over-reading. General practitioner review/12-lead ECG was facilitated for suspected new AF. An automated AF algorithm was retrospectively applied to collected iECGs. Cost-effectiveness analysis incorporated costs of iECG screening, and treatment/outcome data from a United Kingdom cohort of 5,555 patients with incidentally detected asymptomatic AF. A total of 1,000 pharmacy customers aged ≥65 years (mean 76 ± 7 years; 44% male) were screened. Newly identified AF was found in 1.5% (95% CI, 0.8–2.5%); mean age 79 ± 6 years; all had CHA2DS2-VASc score ≥2. AF prevalence was 6.7% (67/1,000). The automated iECG algorithm showed 98.5% (CI, 92–100%) sensitivity for AF detection and 91.4% (CI, 89–93%) specificity. The incremental cost-effectiveness ratio of extending iECG screening into the community, based on 55% warfarin prescription adherence, would be $AUD5,988 (€3,142; $USD4,066) per Quality Adjusted Life Year gained and $AUD30,481 (€15,993; $USD20,695) for preventing one stroke. Sensitivity analysis indicated cost-effectiveness improved with increased treatment adherence.Screening with iECG in pharmacies with an automated algorithm is both feasible and cost-effective. The high and largely preventable stroke/thromboembolism risk of those with newly identified AF highlights the likely benefits of community AF screening. Guideline recommendation of community iECG AF screening should be considered.

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