Cost-effectiveness modelling of novel oral anticoagulants incorporating real-world elderly patients with atrial fibrillation

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• 作者：Ying Jiao Zhao^a ; ^{ying_jiao_zhao@nhg.com.sg" class="auth_mail" title="E-mail the corresponding author} ; Liang Lin^a ; Hui Jun Zhou^a ; Keng Teng Tan^b ; Aik Phon Chew^c ; Chee Guan Foo^d ; Chia Theng Daniel Oh^e ; Boon Peng Lim^a ; Wee Shiong Lim^c
• 关键词：Cost-effectiveness analysis ; Anticoagulant ; Atrial fibrillation ; Stroke
• 刊名：International Journal of Cardiology
• 出版年：2016
• 出版时间：1 October 2016
• 年：2016
• 卷：220
• 期：Complete
• 页码：794-801
• 全文大小：533 K

文摘

Novel oral anticoagulants (NOACs) expand the treatment options for patients with atrial fibrillation (AF). Their benefits need to be weighed against the risk–benefit ratio in real-world elderly patients, prompting this cost-effectiveness study of NOACs (apixaban, dabigatran, edoxaban and rivaroxaban), warfarin and aspirin for stroke prevention in AF.

Methods

Applying effectiveness estimates from a network meta-analysis involving over 800,000 patients from randomised controlled trials and observation studies, our Markov model projected cost and health outcomes for a cohort of 65-year-old AF patients over a life-time. We performed subgroup analysis stratified by age (65–74 and ≥ 75 years), with further analysis limited to observational studies involving dabigatran and rivaroxaban.

Results

Compared to warfarin, NOACs (except dabigatran 110) were associated with incremental cost-effectiveness ratios ranging from USD 24,476 to USD 41,448 that were within cost-effectiveness threshold of USD 49,700 (one gross domestic product per capita in Singapore in 2015). Aspirin regimens were dominated. In elderly aged ≥ 75 years, cost effectiveness of NOACs (except apixaban) decreased, owing to worsened performance in safety profile. Analysis limited to observational studies revealed that dabigatran 150 and rivaroxaban were not cost-effective, reflecting increased bleeding risks in non-controlled settings. Threshold analyses revealed that apixaban was no longer cost-effective at two to three times higher bleeding risk.

Conclusions

Whilst NOACs are cost-effective in the younger elderly compared to warfarin, their benefits appear to be offset by worsened risk profile in older elderly, especially in non-controlled settings. Decisions on appropriate AF treatment should balance treatment-related benefits, risks, and patient preference.