Comparison of Cost-Effectiveness of Anticoagulation with Dabigatran, Rivaroxaban and Apixaban in Patients with Non-Valvular Atrial Fibrillation Across Countries

Abstract

1164 The three new oral anticoagulants (NOAC) dabigatran 110mg bid and 150mg bid, investigated in the RE-LY trial, rivaroxaban 20mg od of the ROCKET trial, and apixaban 5mg bid of the ARISTOTLE trial showed equivalent or superior efficacy and safety compared to warfarin in these patients. We performed a cost-effectiveness analysis for these NOACs in Germany and compared the quality of life (QALY), incremental cost effectiveness ratios (ICER), and total costs across those countries form where these data are published. The base case population was a hypothetical cohort of patients 65 years or older with AF who were at increased risk for stroke (CHADS2-score >1) and had no contraindications to anticoagulation. The time horizon was based on the life expectancy of the German population. The QALYs, health insurance costs, and ICER for the NOACs compared with warfarin were calculated for each study. The sensitivity analysis was performed for different base case prices. The Markov decision model was adopted using the TreeAge Pro 2011 program. The data of the outcomes of ischemic stroke and cerebral embolism, major and intracerebral haemorrhage, myocardial infarction, and mortality were taken from the 3 studies comparing the NOAC with INR-adjusted warfarin. Prices for clinical events and for outpatient care were taken from the institute for payment regulations in German hospitals (InEK). The base-case analysis of a 65 years old person with a >2 CHADS2 score using the data from the RE-LY study resulted in 11.41 QALYs for warfarin, 11.53 QALYs for dabigatran 110mg bid, 11.66 QALYs for dabigatran 150 mg bid. ICERs per QALY were 49640€ for dabigatran 110 mg bid and 49590€ for dabigatran 150 mg bid versus warfarin. The same base-case analysis using the data from the ROCKET AF study resulted in 10.79 QALYs for warfarin versus 11.05 QALYs for rivaroxaban. ICERs per QALY were 48980€ for rivaroxaban versus warfarin. The base-case analysis using the data from the ARISTOTLE study resulted and 11.04 QALYs for warfarin versus 11.38 QALYs for apixaban. ICERs per QALY were 49720€ for apixaban versus warfarin. According the Markov Model the daily value based daily prices were 1.25€ for dabigatran 110 mg bid, 2.50€ for dabigatran 150 mg bid, 2.60€ for rivaroxaban, and 3.10€ for apixaban in Germany. The model was highly sensitive to the daily costs for the NOACs but relatively insensitive to other model inputs. Calculating the range of NOAC prices from 0.2 to 10 Euro versus the ICERs dabigatran 110 mg bid produced the highest increase of ICERs over this range of daily costs (Tukey-Kramer test, p<0.05) Comparing these data across countries using the published data shows that the willingness to pay per QALY as well as differences in treatment costs between substantially influences the daily prices of the NOACs. The data demonstrate the necessity to analyse the cost-effectiveness separately for every study due to differences in the INR-adjusted warfarin treated control group. The better the outcome during treatment with warfarin the lower is the benefit of the NOAC. The tendency of the cost-effectiveness calculated by the Markov model is comparable across countries. Disclosures: No relevant conflicts of interest to declare.

A cost-effectiveness analysis model of Preventicus atrial fibrillation screening from the point of view of statutory health insurance in Germany

“…This amounts to a cost of €2025 per bleeding. Less severe bleedings: to simplify, the cost assumption by [53] was adopted for the amount of €50 per bleeding.…”

The Gap Between Economic Evaluations and Clinical Practice: A Systematic Review of Economic Evaluations on Dabigatran for Atrial Fibrillation

“…The study that included the most context-independent factors is the one from Zheng et al (41), which was performed for the United Kingdom, and only excluded pulmonary embolism and dyspepsia from the model. The three studies with the lowest inclusion of relevant context-independent factors (19;36;46) covered only 30 percent of factors, although it was unclear whether one study adequately included dyspepsia in the model (19).…”

“…All studies included the health outcomes ischemic stroke and intracranial hemorrhage in their model. In all but one study (36), a lifetime horizon for treatment with dabigatran and VKAs was applied. Only in two studies was pulmonary embolism taken into account (25;37).…”

“…Studies were published between 2011 and 2015. Six studies were performed for the United States (18-23), three for Canada (24)(25)(26), seventeen for European countries (27)(28)(29)(30)(31)(32)(33)(34)(35)(36)(37)(38)(39)(40)(41)(42)(43), and three for other countries (South Africa, Taiwan, and Singapore) (44)(45)(46).…”

New oral anticoagulants in patients with nonvalvular atrial fibrillation: a review of pharmacokinetics, safety, efficacy, quality of life, and cost effectiveness

“…For a baseline 65-year-old patient with AF and CHADS 2 >1 or equivalent in a time range over 20 years, the cost-utility analysis for warfarin ranged from 7,622€ to 9,069€ and for NOAC from 19,537€ to 20,048€. 65 …”