Economic Evaluation of Percutaneous Left Atrial Appendage Occlusion, Dabigatran, and Warfarin for Stroke Prevention in Patients With Nonvalvular Atrial Fibrillation

BACKGROUND: Percutaneous left atrial appendage (LAA) occlusion and novel pharmacological therapies are now available to manage stroke risk in patients with nonvalvular atrial fibrillation; however, the cost-effectiveness of LAA occlusion compared with dabigatran and warfarin in patients with nonvalvular atrial fibrillation is unknown. METHODS AND RESULTS: Cost-utility analysis using a patient-level Markov microsimulation decision analytic model with a lifetime horizon was undertaken to determine the lifetime costs, quality-adjusted life years, and incremental cost-effectiveness ratio of LAA occlusion in relation to dabigatran and warfarin in patients with nonvalvular atrial fibrillation at risk for stroke without contraindications to oral anticoagulation. The analysis was performed from the perspective of the Ontario Ministry of Health and Long Term Care, the third-party payer for insured health services in Ontario, Canada. Effectiveness and utility data were obtained from the published literature. Cost data were obtained from the Ontario Drug Benefits Formulary and the Ontario Case Costing Initiative. Warfarin therapy had the lowest discounted quality-adjusted life years at 4. 55, followed by dabigatran at 4. 64 and LAA occlusion at 4. 68. The average discounted lifetime cost was 21 429 for a patient taking warfarin, 25 760 for a patient taking dabigatran, and 27 003 for LAA occlusion. Compared with warfarin, the incremental cost-effectiveness ratio for LAA occlusion was 41 565. Dabigatran was extendedly dominated. CONCLUSIONS: Percutaneous LAA occlusion represents a novel therapy for stroke reduction that is cost-effective compared with warfarin for patients at risk who have nonvalvular atrial fibrillation.