Oral anticoagulants for primary prevention, treatment and secondary prevention of venous thromboembolic disease, and for prevention of stroke in atrial fibrillation: systematic review, network meta-analysis and cost-effectiveness analysis

Abstract

outside the submitted work, and AntiCoagulation Europe (ACE), a registered charity, the aims of which include raising awareness of the risk and prevention of thrombosis, and providing information, education and support to people who are on anticoagulation therapy for any duration, including long term for those with chronic conditions. Diane Eaton works with ACE in an associate consultant capacity in the role of Project Development Manager. She has over 40 years of personal experience of anticoagulation therapy and represents ACE as a patient expert at the National Institute for Health and Care Excellence (NICE). On behalf of the charity, she has provided the patient perspective for the submissions for the technology appraisals for the novel oral anticoagulants (NOACs) and Diagnostic Guidance for Coagulometers over a 4-year period. Please note that the financial information has been prepared by Eve Knight, Chief Executive of AntiCoagulation Europe, for the purpose of inclusion in this document. Published March 2017 DOI: 10.3310/hta21090This report should be referenced as follows:Sterne JAC, Bodalia PN, Bryden PA, Davies PA, López-López JA, Okoli GN, et al. Oral anticoagulants for primary prevention, treatment and secondary prevention of venous thromboembolic disease, and for prevention of stroke in atrial fibrillation: systematic review, network meta-analysis and cost-effectiveness analysis. Health Technol Assess 2017;21(9). Reports are published in Health Technology Assessment (HTA) if (1) they have resulted from work for the HTA programme, and (2) they are of a sufficiently high scientific quality as assessed by the reviewers and editors. Health Technology Assessment is indexed and abstracted inReviews in Health Technology Assessment are termed 'systematic' when the account of the search appraisal and synthesis methods (to minimise biases and random errors) would, in theory, permit the replication of the review by others. HTA programmeThe HTA programme, part of the National Institute for Health Research (NIHR), was set up in 1993. It produces high-quality research information on the effectiveness, costs and broader impact of health technologies for those who use, manage and provide care in the NHS. 'Health technologies' are broadly defined as all interventions used to promote health, prevent and treat disease, and improve rehabilitation and long-term care.The journal is indexed in NHS Evidence via its abstracts included in MEDLINE and its Technology Assessment Reports inform National Institute for Health and Care Excellence (NICE) guidance. HTA research is also an important source of evidence for National Screening Committee (NSC) policy decisions.For more information about the HTA programme please visit the website: http://www.nets.nihr.ac.uk/programmes/hta This reportThe research reported in this issue of the journal was funded by the HTA programme as project number 11/92/17. The contractual start date was in October 2013. The draft report began editorial review in May 2015 and was accepted for publication in...

Screening strategies for atrial fibrillation: a systematic review and cost-effectiveness analysis

“…Then a Markov model tracks AF-related events and mortality conditional on anticoagulant therapy. Our previously published Markov model (DOAC model) 37 was based on a network meta-analysis of all trials comparing DOACs with warfarin (INR range 2-3) to capture the lifetime costs and benefits of anticoagulation therapy in AF. Figure 17 illustrates the decision tree used to compare population (S1) and opportunistic (S2) screening with current practice (S0, no screening).…”

“…In the base case we assumed that all of the individuals not contraindicated and prescribed anticoagulation therapy use DOACs. We assumed that the most cost-effective treatment (apixaban) in the DOAC model 37 is used for all patients who receive DOACs, although it should be noted that similar results would be obtained using other DOACS. 37 In the sensitivity analyses we assumed that 50% use DOACs and the remainder use warfarin (INR range 2-3).…”

“…We assumed that the most cost-effective treatment (apixaban) in the DOAC model 37 is used for all patients who receive DOACs, although it should be noted that similar results would be obtained using other DOACS. 37 In the sensitivity analyses we assumed that 50% use DOACs and the remainder use warfarin (INR range 2-3). We assumed that individuals with a CHA 2 DS 2 -VASc score of ≤ 1, in whom OACs are not recommended, 11 and patients contraindicated to, not prescribed or choosing not to take OACs, would receive aspirin.…”

“…The cost-effectiveness of anticoagulant therapy (warfarin or DOACs) to prevent stroke in eligible AF patients has been established, 37 indicating that it is an efficient use of NHS resources. However, the trials informing these assessments were not conducted in screen-detected cases.…”

“…The cost-effectiveness of OACs in non-screen-detected AF has recently been demonstrated. 37 A recent report for the National Screening Committee 24 concluded that there was a need to formally assess the cost-effectiveness of a screening programme for AF, and that such a cost-effectiveness analysis should include both costs of detecting undiagnosed cases of AF and also allow for stroke risk in screendetected AF to be lower than that in clinically diagnosed AF. …”