Key result
Switching from VKA to DOAC yields no survival benefit and is not cost-effective in AF.
Why the study?
Evidence on the real-world causal effects of switching patients from VKA to DOAC for stroke prevention in AF was lacking.
Does switching to a direct-acting oral anticoagulant (DOAC) improve survival or prove cost-effective compared to maintaining vitamin K antagonist therapy in atrial fibrillation patients?
Cohort (n=791)
Yes
Does switching to a direct-acting oral anticoagulant (DOAC) improve survival or prove cost-effective compared to maintaining vitamin K antagonist therapy in atrial fibrillation patients?
Switching well-managed AF patients from a vitamin K antagonist to a DOAC may not be cost-effective and does not confer an additional survival benefit.
May not support switching stable AF patients from VKA to DOAC; leaves open whether randomized data would show benefit in other settings.
AIMS: Direct-acting oral anticoagulants (DOACs) have, to a substantial degree, replaced vitamin K antagonists (VKA) as treatments for stroke prevention in atrial fibrillation (AF) patients. However, evidence on the real-world causal effects of switching patients from VKA to DOAC is lacking. We aimed to assess the empirical incremental cost-effectiveness of switching patients to DOAC compared with maintaining VKA treatment. METHODS: The target trial approach was applied to the prospective observational Swiss-AF cohort, which enrolled 2415 AF patients from 2014 to 2017. Clinical data, healthcare resource utilisation and EQ-5D-based utilities representing quality of life were collected in yearly follow-ups. Health insurance claims were available for 1024 patients (42.4%). Overall survival, quality-of-life, costs from the Swiss statutory health insurance perspective and cost-effectiveness were estimated by emulating a target trial in which patients were randomly assigned to switch to DOAC or maintain VKA treatment. RESULTS: 228 patients switching from VKA to DOAC compared with 563 patients maintaining VKA treatment had no overall survival advantage over a 5-year observation period (HR 0.99, 95% CI 0.45, 1.55). The estimated gain in quality-adjusted life years (QALYs) was 0.003 over the 5-year period at an incremental costs of CHF 23 033 (€ 20 940). The estimated incremental cost-effectiveness ratio was CHF 425 852 (€ 387 138) per QALY gained. CONCLUSIONS: Applying a causal inference method to real-world data, we could not demonstrate switching to DOACs to be cost-effective for AF patients with at least 1 year of VKA treatment. Our estimates align with results from a previous randomised trial.
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Aebersold et al. (2024) conducted a cohort in Atrial Fibrillation on Vitamin K Antagonists (n=791). Switching to Direct-Acting Oral Anticoagulants (DOACs) vs. Maintaining Vitamin K Antagonist (VKA) treatment was evaluated on Overall survival (HR 0.99, 95% CI 0.45-1.55). Switching from a vitamin K antagonist to a direct-acting oral anticoagulant in patients with atrial fibrillation did not confer an overall survival advantage (HR 0.99) and was not cost-effective (incremental cost of CHF 425,852 per QALY gained) over 5 years.
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