Cost-Effectiveness of Apixaban Compared With Aspirin for Stroke Prevention in Atrial Fibrillation Among Patients Unsuitable for Warfarin

Abstract

Background-Compared with aspirin, apixaban reduces stroke risk in atrial fibrillation (AF) patients unsuitable for warfarin by 63% but does not increase major bleeding. We sought to determine the cost-effectiveness of apixaban versus aspirin. Methods and Results-Using the Apixaban versus Acetylsalicylic Acid to Prevent Stroke in Atrial Fibrillation PatientsWho Have Failed or Are Unsuitable for Vitamin-K Antagonist Treatment (AVERROES) trial and other studies, we constructed a Markov model to evaluate the costs (2011US$), quality-adjusted life-years (QALYs), and incremental cost-effectiveness of apixaban versus aspirin from the Medicare perspective. Our base-case assumed a 70-year-old AF patient cohort with a CHADS 2 score=2 and a lower-risk of bleeding. We used a 1-month cycle-length and ran separate base-case analyses assuming a trial-length (1-year) and a longer-term (10-year) follow-up. Total costs/patient were $3454 and $1805 for apixaban and aspirin in the trial-length and $44 232 and $50 066 in the 10-year model. Corresponding QALYs were 0.96 and 0.96 in the trial-length and 6.87 and 6.51 in the 10-year model, making apixaban inferior in the first model but dominant in the latter. Conclusions were sensitive to baseline stroke rate in both models, and the monthly cost of major stroke, relative risk of stroke, and prior vitamin-K antagonist use in the life-time model. Probabilistic sensitivity analysis suggested apixaban would only be a cost-effective alternative (<$50 000/QALY) to aspirin 11% of the time in the trial-length model, but cost-effective or dominant 96.7% and 87.5% of iterations in the 10-year model. Conclusions-In our trial-length model, apixaban was more costly and no more effective than aspirin; however, as followup was extended, apixaban became cost-effective and eventually dominant. (Circ Cardiovasc Qual Outcomes. 2012; 5:472-479.)

Stroke and Thromboembolism in Atrial Fibrillation

“…Furthermore, limited data on the other new oral anticoagulants, rivaroxaban and apixaban, have been published recently. 75, 76 Even more data 77-79 and comparative efforts are awaited to facilitate optimal decision making in the antithrombotic management of AF patients.…”

Cost of Acute Stroke Care for Patients with Atrial Fibrillation Compared with Those in Sinus Rhythm

“…Anticoagulation with warfarin or the novel oral anticoagulants (NOACs) has been shown to reduce the risk of stroke in patients with AF by at least two-thirds [5,6]. A large number of economic analyses have recently been published assessing the cost effectiveness of NOACs, given their greater market cost; however, the vast majority of these studies do not use AFspecific cost data [7][8][9][10][11][12][13][14]. Even the UK National Institute of Health and Care Excellence (NICE) technology appraisals of the NOACs utilise stroke costs based on payment by results tariff, and prior systematic reviews that do not separate the costs of stroke according to AF status [15,16].…”

Cost Effectiveness of Apixaban Versus Aspirin for Stroke Prevention in Patients with Non-Valvular Atrial Fibrillation in Belgium

“…Previous cost-effectiveness studies have demonstrated that the drug is a dominant treatment option or cost-effective treatment option to aspirin in the USA and UK, respectively [11,12] but this evidence cannot be assumed to hold for other countries, as geographic variations in healthcare resource use and clinical practice suggest that findings may not be generalisable in this way [13]. Ultimately, assessing how closely health economic outcomes for different countries correlate with each other requires specific evaluations to be conducted for those territories.…”