AimsAtrial fibrillation (AF) patients with contraindications to oral anticoagulation have had few options for stroke prevention. Recently, a novel oral anticoagulant, apixaban, and percutaneous left atrial appendage closure (LAAC) have emerged as safe and effective therapies for stroke risk reduction in these patients. This analysis assessed the cost effectiveness of LAAC with the Watchman device relative to apixaban and aspirin therapy in patients with non-valvular AF and contraindications to warfarin therapy.Methods and resultsA cost-effectiveness model was constructed using data from three studies on stroke prevention in patients with contraindications: the ASAP study evaluating the Watchman device, the ACTIVE A trial of aspirin and clopidogrel, and the AVERROES trial evaluating apixaban. The cost-effectiveness analysis was conducted from a German healthcare payer perspective over a 20-year time horizon. Left atrial appendage closure yielded more quality-adjusted life years (QALYs) than aspirin and apixaban by 2 and 4 years, respectively. At 5 years, LAAC was cost effective compared with aspirin with an incremental cost-effectiveness ratio (ICER) of €16 971. Left atrial appendage closure was cost effective compared with apixaban at 7 years with an ICER of €9040. Left atrial appendage closure was cost saving and more effective than aspirin and apixaban at 8 years and remained so throughout the 20-year time horizon.ConclusionsThis analysis demonstrates that LAAC with the Watchman device is a cost-effective and cost-saving solution for stroke risk reduction in patients with non-valvular AF who are at risk for stroke but have contraindications to warfarin.

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Objective: To evaluate the clinical and economic impact of adopting noninvasive prenatal testing (NIPT) using circulating cell-free DNA as a first-line screening method for trisomy 21, 18, and 13 in the general pregnancy population. Methods: A decision-analytical model was developed to assess the impact of adopting NIPT as a primary screening test compared to conventional screening methods. The model takes the Belgium perspective and includes only the direct medical cost of screening, diagnosis, and procedure-related complications. NIPT costs are EUR 260. Clinical outcomes and the cost per trisomy detected were assessed. Sensitivity analysis measured the impact of NIPT false-positive rate (FPR) on modelled results. Results: The cost per trisomy detected was EUR 63,016 for conventional screening versus EUR 66,633 for NIPT, with a difference of EUR 3,617. NIPT reduced unnecessary invasive tests by 94.8%, decreased procedure-related miscarriages by 90.8%, and increased trisomies detected by 29.1%. Increasing the FPR of NIPT (from < 0.01 to 1.0%) increased the average number of invasive procedures required to diagnose a trisomy from 2.2 to 4.5, respectively. Conclusion: NIPT first-line screening at a reasonable cost is cost-effective and provides better clinical outcomes. However, modelled results are dependent on the adoption of an NIPT with a low FPR.

Purpose: Medication nonadherence is a significant and multidimensional problem contributing to an increased risk of morbidity and mortality. Inconveniences in pharmacy and home contexts may increase nonadherence. This research examined inconveniences in pharmacy and home contexts associated with self-reported nonadherence, controlling for demographic and medication-taking covariates. Methods: Data from 4682 individuals who reported self-managing medications in an online marketing survey between October and December 2017 were analyzed in this secondary analysis. Nonadherence was dichotomized using a single question about likelihood to take medications as prescribed (adherence=always; nonadherence=most of the time, some of the time, never). Multivariable logistic regression with backwards elimination was used to examine the pharmacy (use of home delivery, number prescriptions picked up and visits to pharmacy) and home context (method used to organize/manage medications, satisfaction, and bother with management) variables and the demographic (age, sex, race/ethnicity, education, income, insurance) and medication (number of oral medications, medication changes and frequency of taking) covariates associated with nonadherence. Results: Overall, 25.8% of the responses indicated nonadherence. Nonadherence was more likely for individuals making fewer separate pharmacy trips (OR 0.98; 95% CI 0.97-0.99); picking up fewer prescriptions (OR 0.96; 95% CI 0.93-0.99); never, rarely or sometimes using mail order compared with always (OR 1.71; 95% CI 1.30-2.26); not satisfied with managing medications (OR 2.13; 95% CI 1.42-3.19); and using pill pouches and being bothered by them (OR 8.28; 95% CI 1.83-37.31). Using pill pouches or a pillbox and not being bothered by them significantly decreased nonadherence likelihood. Younger and female respondents and those reporting medication changes in the last year were also more likely to report nonadherence. Conclusion: Though reasons for nonadherence are multidimensional, this study suggests that inconveniences in both the pharmacy and home context are important. Improving adherence requires addressing issues of inconvenience across the care continuum.