Patient self‐management of anticoagulation therapy: a trial‐based cost‐effectiveness analysis

Abstract

SummaryDemand for anticoagulation management is increasing due to an expansion of clinical indications for therapy. One possible model of care to meet demand is patient self-management (PSM), beneficial to patients who need control over their condition. This study aimed to determine the cost and cost-effectiveness of PSM of anticoagulation compared with routine clinicbased care for patients receiving long-term anticoagulation. A cost-utility analysis was conducted alongside a randomised controlled trial; 617 patients were recruited and followed up for 12 months. There was no significant difference in mean quality-adjusted life years (QALYs) between groups -after adjusting for baseline, the mean difference in QALYs was 0AE009 (95% CI, )0AE012 to 0AE030). Overall mean healthcare costs in the PSM arm were significantly higher at £417 (CI £394-£442) compared with £122 (CI £103-£144) in the control arm. Therefore, using a formal cost-effectiveness analysis, PSM of anticoagulation does not appear to be cost-effective. However, PSM may have other benefits in relieving pressure on traditional clinic-based care, and the cost-effectiveness of this model of care for some subgroups of anticoagulation patients needs to be explored further.

The clinical effectiveness and cost-effectiveness of point-of-care tests (CoaguChek system, INRatio2 PT/INR monitor and ProTime Microcoagulation system) for the self-monitoring of the coagulation status of people receiving long-term vitamin K antagonist therapy, compared with standard UK practice: systematic review and economic evaluation

“…These findings were, however, sensitive to the unit costs applied to standard care monitoring visits. Applying the alternative standard monitoring unit costs estimated by Jowett and colleagues, 87 the opposite was observed, with self-monitoring dominating secondary care monitoring but being dominated by primary care monitoring.…”

“…Contrary to this, several studies applied large effect estimates favouring self-monitoring in terms of TTR, thromboembolic events and/or mortality, and, subsequently, found self-monitoring strategies to be cost-saving or cost-effective. 33,86,88 In relation to the scope of this assessment, the two most relevant studies are those reported by Jowett and colleagues 87 and Connock and colleagues. 21 These economic evaluations were largely based on the same trial conducted in the UK.…”

“…Finally, the baseline utility value for people with atrial fibrillation or mechanical heart valve who were stable was taken as the baseline EQ-5D value of patients enrolled in the SMART trial (0.738). 87 This value was applied to 65-to 70-year-old people. The difference between the UK EQ-5D population norm for 65-to 70-year-olds and the utility estimate from the SMART trial (0.042) was used to estimate age-specific baseline utilities in the model.…”

“…Estimates of time spent in therapeutic range, warfarin monitoring costs and baseline health state utility (measured using the EQ-5D) were derived from a previous RCT conducted in the UK with an accompanying economic evaluation. 87 The cost of INR devices (assumed to be paid for by the NHS) were annuitised over a 3-year period, and it was assumed that where patients stopped using these for any reason within 3 years, 75% would be reused by another patient. Risks of thromboembolic, major haemorrhagic and minor haemorrhagic events were estimated from a variety of published sources by time spent in, above and below the specified INR therapeutic range.…”

“…64 Jowett and colleagues carried out the economic analysis alongside the Self-Management of Anticoagulation, a Randomised Trial (SMART), where people in the control arm received a mix of standard primary and secondary care monitoring. 87 A unit cost per visit (accounting for staff time, equipment, consumables and overheads) was estimated for each care setting from a sample of NHS providers. The resultant cost estimates (per visit) for different types of standard care are presented in Table 20, inflated to 2011-12 prices.…”