Cost-Effectiveness of Oral Anticoagulants for Ischemic Stroke Prophylaxis Among Nonvalvular Atrial Fibrillation Patients

Abstract

Background and Purpose— The objective of the study is to compare the cost-effectiveness of oral anticoagulants among atrial fibrillation patients at an increased stroke risk. Methods— A Markov model was constructed to project the lifetime costs and quality-adjusted survival (QALYs) of oral anticoagulants using a private payer’s perspective. The distribution of stroke risk (CHADS 2 score: congestive heart failure, hypertension, advanced age, diabetes mellitus, stroke) and age of the modeled population was derived from a cohort of commercially insured patients with new-onset atrial fibrillation. Probabilities of treatment specific events were derived from published clinical trials. Event and downstream costs were determined from the cost of illness studies. Drug costs were obtained from 2015 National Average Drug Acquisition Cost data. Results— In the base case analysis, warfarin was the least costly ($46 241; 95% CI, 44 499–47 874) and apixaban had the highest QALYs (9.38; 95% CI, 9.24–9.48 QALYs). Apixaban was found to be a cost-effective strategy over warfarin (incremental cost-effectiveness ratio=$25 816) and dominated other anticoagulants. Probabilistic sensitivity analysis showed that apixaban had at least a 61% chance of being the most cost-effective strategy at willingness to pay value of $100 000 per QALY. Among patients with CHADS 2 ≥3, dabigatran was the dominant strategy. The model was sensitive to efficacy estimates of apixaban, dabigatran, and edoxaban and the cost of these drugs. Conclusions— All the newer oral anticoagulants compared were more effective than adjusted dosed warfarin. Our model showed that apixaban was the most effective anticoagulant in a general atrial fibrillation population and has an incremental cost-effectiveness ratio <$50 000/QALY. For those with higher stroke risk (CHADS 2 ≥3), dabigatran was the most cost-effective treatment option.

Direct oral anticoagulants in patients with hypertrophic cardiomyopathy and atrial fibrillation

“…VKAs 15 , and that non-valvular AF patients are more satisfied with medical care when treated with NOACs 12 .…”

TIMI‐AF score and cardiovascular events in vitamin K antagonists‐naïve outpatients with atrial fibrillation

“…However, American guidelines and the NICE guidelines consider DOACs to be equal and advocate a joint decision with the patient. While cost‐effective, these drugs do imply an additional cost . The current world economic framework makes it necessary to prioritize the use of these drugs in patients for whom they have a clear added value.…”

“…While cost-effective, these drugs do imply an additional cost. 28 The current world economic framework makes it necessary to prioritize the use of these drugs in patients for whom they have a clear added value. Both in health systems with more limited resources and in those where the patient covers the cost of medication, it is important to have tools such as the TIMI-AF score.…”

Predicting Cost‐Effectiveness of Generic vs. Brand Dabigatran Using Pharmacometric Estimates Among Patients with Atrial Fibrillation in the United States

“…A Markov model was adapted from Shah et al to model the disease progression of AF ( Figures and ) . We relaxed the cohort assumption inherent with Markov models to allow variations in patient clinical characteristics, such as stroke, bleed risks, and age.…”