Cost-Effectiveness of Oral Anticoagulants for Treatment of Atrial Fibrillation

Abstract

Background-New anticoagulants may improve health outcomes in patients with atrial fibrillation, but it is unclear whether their use is cost-effective. Methods and Results-A Markov state transition was created to compare 4 therapies: dabigatran 150 mg BID, apixaban 5 mg BID, rivaroxaban 20 mg QD, and warfarin therapy. The population included those with newly diagnosed atrial fibrillation who were eligible for treatment with warfarin. Compared with warfarin, apixaban, rivaroxaban, and dabigatran, costs were $93 063, $111 465, and $140 557 per additional quality-adjusted life year gained, respectively. At a threshold of $100 000 per quality-adjusted life year, apixaban provided the greatest absolute benefit while still being cost-effective, although warfarin would be superior if apixaban was 2% less effective than expected. Although apixaban was the optimal strategy in our base case, in probabilistic sensitivity analysis, warfarin was optimal in an equal number of iterations at a cost-effectiveness threshold of $100 000 per quality-adjusted life year. Conclusions-While at a standard cost-effectiveness threshold of $100 000 per quality-adjusted life year, apixaban seems to be the optimal anticoagulation strategy; this finding is sensitive to assumptions about its efficacy and cost. In sensitivity analysis, warfarin seems to be the optimal choice in an equal number of simulations. As a result, although all the novel oral anticoagulants produce greater quality-adjusted life expectancy than warfarin, they may not represent good value for money.

Intracranial hemorrhage risk with the new oral anticoagulants: a systematic review and meta-analysis

“…Treatment with NOACs waives such burden and lightens resources consumption. NOACs are also likely to be cost-effective, which is of extreme importance for policy-makers [42][43][44].…”

Left Atrial Appendage Closure Device in Atrial Fibrillation

“…17 When comparing warfarin with the novel oral anticoagulants, warfarin was still most cost-effective, although one analysis determined that the novel agents produced a greater quality-adjusted life expectancy than warfarin. 18 Are there unknown late costs to left atrial appendage (LAA) occlusion device therapy? We do not have data on 10-year-old Watchman implants.…”

A Clinical Prediction Model for Time in Therapeutic Range While on Warfarin in Newly Diagnosed Atrial Fibrillation

“…Meta-analyses have reported small improvements in efficacy and safety with DOACs compared with warfarin; however, these modest improvements must be considered with the higher cost of DOACs, which have created uncertainty about their overall cost-effectiveness. [7][8][9][10] Other concerns limiting more widespread use of DOACs include an inability to monitor their anticoagulation effects, short half-lives that increase thrombosis risk when doses are missed, and lack of experience with reversal agents that may be needed in urgent settings. 11 Alternatively, warfarin is an inexpensive, long-used, well-researched, and effective therapeutic, associated with a 64% reduction in ischemic stroke in nonvalvular AF compared with placebo.…”