(Cost-effectiveness analysis of first-line NOAC prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation)

Q: What is the clinical evidence from this study?

Population: Non-valvular atrial fibrillation. Intervention: NOACs (apixaban, dabigatran, edoxaban, rivaroxaban) vs. Warfarin. Primary outcome: Incremental cost-effectiveness ratio (ICER) per Quality Adjusted Life Year (QALY) gained (ICER 479,014 CZK/QALY (apixaban vs warfarin)).

Miloš Táborský; Aleš Tomek; Robert Čihák; Ondřej Škoda; Josef Daněk; Martin Kolek

doi:10.33678/cor.2019.058

August 11, 2019Cor et VasaOpen Access

(Cost-effectiveness analysis of first-line NOAC prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation)

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Key result

NOACs were highly cost-effective compared to warfarin for stroke prevention in non-valvular atrial fibrillation, with apixaban being the most cost-effective at an ICER of 479,014 CZK per QALY gained.

Why the study?

The study was conducted to compare the costs and benefits of NOACs versus warfarin as the standard of care for first-line prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation.

Are NOACs cost-effective compared to warfarin for first-line prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation?

Key Points

To evaluate the lifetime cost-effectiveness and clinical benefits of novel oral anticoagulants compared to standard warfarin therapy as first-line stroke prevention in patients with non-valvular atrial fibrillation.
A Markov model evaluated cost-utility from the healthcare payer perspective across a lifetime horizon.
Clinical input data were derived from major clinical trials: ARISTOTLE, RE-LY, ROCKET-AF, and ENGAGE AF-TIMI.
All four NOACs generated gains in both quality-adjusted life years (QALY) and life-years gained (LYG) compared to warfarin: apixaban gained 0.184 QALYs and 0.177 LYG; dabigatran gained 0.121 QALYs and 0.099 LYG; edoxaban gained 0.149 QALYs and 0.129 LYG; rivaroxaban gained 0.126 QALYs and 0.102 LYG.
The incremental cost-effectiveness ratios per QALY gained versus warfarin were 479,014 CZK for apixaban, 563,057 CZK for edoxaban (60 mg), 582,768 CZK for dabigatran (150 mg), and 664,238 CZK for rivaroxaban.
All NOAC options fell well below the national willingness-to-pay threshold of 1.2 million CZK per QALY gained.

Structured PICO

Are NOACs cost-effective compared to warfarin for first-line prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation?

P

Population

A Markov model simulating a lifetime horizon for a hypothetical cohort of 70-year-old patients (35.3% female) with non-valvular atrial fibrillation and at least one stroke risk factor, evaluating the cost-effectiveness of NOACs versus warfarin from the perspective of the Czech healthcare payer.

I

Intervention

Novel oral anticoagulants (NOACs: apixaban, dabigatran 150 mg, edoxaban 60 mg, rivaroxaban)

C

Comparator

Warfarin

O

Outcome

Incremental cost-effectiveness ratio (ICER) per Quality Adjusted Life Year (QALY) and Life-Years Gained (LYG) over a lifetime horizon

Main Result

Effect estimate: ICER 479,014 CZK/QALY (apixaban vs warfarin)

NOACs are a highly cost-effective alternative to warfarin for the first-line prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation in the Czech Republic.

Limitations

Indirect comparison of NOACs based on a network meta-analysis rather than head-to-head trials.
General mortality for the first 1.8 years was based solely on the ARISTOTLE trial for all NOACs.
Results reflect clinical trial settings and may not fully capture real-world clinical practice outcomes.
Utility values were sourced from various publications, which may introduce inconsistency.

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Implication

May inform Czech NOAC reimbursement for non-valvular AF; leaves open need for updated local real-world data.

Abstract

Ăvod: Fibrilace sĂnĂ (FS) je poruchou srdeÄnĂho rytmu s prevalencĂ 3,37 % populace, kterĂĄ roste s vÄkem.1 Pacienti s FS majĂ vysokĂŠ riziko cĂŠvnĂ mozkovĂŠ pĹĂhody (CMP) a systĂŠmovĂŠ embolizace (SE), kterĂŠ dĂĄle roste, pokud pacient prodÄlal tranzitornĂ ischemickou ataku (TIA) nebo CMP. CĂl: CĂlem farmakoekonomickĂŠho hodnocenĂ je porovnĂĄnĂ nĂĄkladĹŻ a pĹĂnosĹŻ lĂŠÄby novĂ˝mi perorĂĄlnĂmi antikoagulancii (novel oral anticoagulants, NOAC) proti warfarinu jako standardu lĂŠÄby v prvnĂ linii prevence CMP a SE u pacientĹŻ s nevalvulĂĄrnĂ fibrilacĂ sĂnĂ. Metody: MarkovĹŻv model hodnotĂ nĂĄkladovou efektivitu se zohlednÄnĂm kvality Ĺživota (CUA) z pohledu plĂĄtce zdravotnĂ pĂŠÄe s vĂ˝sledkem v podobÄ pĹĂrĹŻstkovĂŠho pomÄru nĂĄkladovĂŠ efektivity (incremental cost-effectiveness ratio, ICER) na QALY (Quality Adjusted Life Years) a ICER na LYG (Life-Years Gained) pro celoĹživotnĂ horizont. Populace pacientĹŻ vychĂĄzĂ z dostupnĂŠ klinickĂŠ evidence, zejmĂŠna ze studiĂ ARISTOTLE, RE-LY, ROCKET-AF, ENGAGE AF-TIMI.2-6 VĂ˝sledky: NOAC dle dosaĹženĂ˝ch vĂ˝sledkĹŻ pĹedstavujĂ ĂşÄinnÄjĹĄĂ variantu lĂŠÄby neĹž warfarin, dosahujĂ vyĹĄĹĄĂ ĂşÄinnosti a bezpeÄnosti za podmĂnky zachovanĂŠ nĂĄkladovĂŠ efektivity. ICER pro apixaban vs. warfarin vychĂĄzĂ na 479 014 KÄ/QALY se ziskem 0,184 QALY a 0,177 LYG; dabigatran 150 mg vs. warfarin 582 768 KÄ se ziskem 0,121 QALY a 0,099 LYG; edoxaban 60 mg vs. warfarin 563 057 KÄ se ziskem 0,149 QALY a 0,129 LYG a koneÄnÄ rivaroxaban vs. warfarin 664 238 KÄ se ziskem 0,126 QALY a 0,102 LYG. ProvedenĂĄ metodickĂĄ a probabilistickĂĄ analĂ˝za senzitivity potvrdily pĹidanou hodnotu lĂŠÄby NOAC ve srovnĂĄnĂ se stĂĄvajĂcĂ terapiĂ. ZĂĄvÄr: NOAC, v porovnĂĄnĂ se souÄasnĂ˝m standardem lĂŠÄby, kterĂ˝m je warfarin, majĂ vÄtĹĄĂ pĹĂnos v podobÄ dosaĹženĂ celkovĂŠho pĹeĹžitĂ, zvĂ˝ĹĄenĂ kvality Ĺživota a zabrĂĄnÄnĂ vzniku kardiovaskulĂĄrnĂch pĹĂhod za splnÄnĂ pĹedpokladu efektivnÄ vynaloĹženĂ˝ch nĂĄkladĹŻ s vĂ˝sledkem ICER hluboko pod hranicĂ ochoty platit 1,2 mil. KÄ.

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Cite This Study

Táborský et al. (2019) studied Non-valvular atrial fibrillation. NOACs (apixaban, dabigatran, edoxaban, rivaroxaban) vs. Warfarin was evaluated on Incremental cost-effectiveness ratio (ICER) per Quality Adjusted Life Year (QALY) gained (ICER 479,014 CZK/QALY (apixaban vs warfarin)). NOACs were highly cost-effective compared to warfarin for stroke prevention in non-valvular atrial fibrillation, with apixaban being the most cost-effective at an ICER of 479,014 CZK per QALY gained.

synapsesocial.com/papers/6a844fec002ab1506fb2ac64 https://doi.org/10.33678/cor.2019.058

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(Cost-effectiveness analysis of first-line NOAC prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation)

Key Points

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

(Cost-effectiveness analysis of first-line NOAC prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation)

Key Points

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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