Cost Effectiveness of Apixaban Versus Aspirin for Stroke Prevention in Patients with Non-Valvular Atrial Fibrillation in Belgium

Cost-effectiveness of the adjuvanted quadrivalent influenza vaccine in the elderly Belgian population

BACKGROUND

Between 2015 and 2019, when 62% of Belgian adults aged ≥ 65 years were vaccinated with standard quadrivalent influenza vaccines, influenza caused an average of 3,905 hospitalizations and 347 premature deaths per year in older adults. The objective of the present analysis was to estimate the cost-effectiveness of the adjuvanted quadrivalent influenza vaccine (aQIV) compared to the standard (SD-QIV) and high-dose (HD-QIV) vaccines in elderly Belgians.

RESEARCH DESIGN AND METHODS

The analysis was based on a static cost-effectiveness model that captured the evolution of patients infected with influenza and was customized with available national data.

RESULTS

Vaccinating adults aged ≥ 65 years with aQIV instead of SD-QIV would decrease the number of hospitalizations by 530 and the number of deaths by 66 in the 2023-2024 influenza season. aQIV was cost-effective compared to SD-QIV with an incremental cost of €15,227/quality-adjusted life year (QALY). aQIV is cost-saving when compared to HD-QIV in the subgroup of institutionalized elderly adults who were granted reimbursement for this vaccine.

CONCLUSION

In a health care system striving to improve the prevention of infectious diseases, a cost-effective vaccine such as aQIV is a key asset to reduce the number of influenza-related hospitalizations and premature deaths in older adults.

PLAIN LANGUAGE SUMMARY

A flu vaccine containing a unique immune boosting additive reduces medical spending by reducing flu hospitalizations and early deaths in the elderly.

Cost Effectiveness of Patient Self-Managed Warfarin Compared with Direct Oral Anticoagulants in Atrial Fibrillation: An Economic Evaluation in a Danish Healthcare Sector Setting

BACKGROUND

Patient self-managed anticoagulant treatment with warfarin (PSM) has been proposed as an alternative to direct oral anticoagulants (DOACs) in patients with non-valvular atrial fibrillation (NVAF); however, direct evidence on the cost effectiveness of PSM compared with DOACs is lacking. We aimed to evaluate the cost effectiveness of PSM versus DOACs for NVAF patients in the Danish healthcare setting using a model-based cost-utility analysis.

METHODS

A cost-utility analysis was performed using a decision-analytic model including two treatment alternatives: continuous PSM and DOACs. The analysis was performed from an extended Danish healthcare sector perspective, including patient-paid costs of medication related to the anticoagulant treatment, with a lifetime horizon. Inputs for the model comprised of probabilities of events, costs in Danish estimates, when possible, and effect in utilities. The probabilities of events are primarily based on real-life data from a direct comparison of PSM and DOACs. The results are presented as the incremental cost-effectiveness ratio (ICER) with an assumed cost-effectiveness threshold of £20,000/quality-adjusted life-year (QALY). Both deterministic and probabilistic sensitivity analyses were performed to investigate the robustness of the results.

RESULTS

The base-analysis showed that PSM was dominant, with a decreased cost of £8495 and an increased QALY accumulation of 0.23 per patient (ICER = -£36,935/QALY). All deterministic sensitivity analyses indicated that PSM was dominant or at least cost effective. The probabilistic sensitivity analysis showed that 95% of the iterations were cost effective.

CONCLUSIONS

The present study found that PSM is dominant (i.e., both more effective and cost saving) compared with DOACs, adding to the scarce evidence of the comparative cost effectiveness of PSM and DOACs in NVAF.

Non-Inferiority of Aspirin for Venous Thromboembolism Prophylaxis After Hip Arthroplasty in a Statewide Registry

BACKGROUND

Uncertainty remains surrounding the use of aspirin as a sole chemoprophylactic agent to reduce the risk of venous thromboembolism (deep vein thrombosis or pulmonary embolism) and bleeding after primary total hip arthroplasty.

METHODS

We performed a non-inferiority analysis of a retrospective cohort of patients undergoing total hip arthroplasty from April 1, 2013 to December 31, 2018. Cases were retrieved from the Michigan Arthroplasty Registry Collaborative Quality Initiative database and performed by 355 surgeons at 61 hospitals throughout Michigan. Surgical setting ranged from small community hospitals to large academic and non-academic centers. The primary outcomes were post-operative venous thromboembolism event or death and bleeding event.

RESULTS

Of the 59,747 patients included, 32,878 (55.03%) were female, and the mean age was 64.5. A total of 462 (0.77%) composite venous thromboembolism events occurred. There were 221 (0.71%) and 129 (0.80%) venous thromboembolism events in patients receiving aspirin only and anticoagulants only, respectively. Aspirin was non-inferior to anticoagulants for composite venous thromboembolism events (odds ratio 0.99, 95% confidence interval 0.79-1.26, P < .001). Bleeding events occurred in 767 (1.28%) patients, with 304 (0.97%) and 281 (1.74%) bleeding events in patients receiving aspirin only and anticoagulants only, respectively. Aspirin was non-inferior to anticoagulants for bleeding events (odds ratio 0.62, 95% confidence interval 0.52-0.74, P < .001).

CONCLUSION

Aspirin is not inferior to other anticoagulants as pharmacologic venous thromboembolism prophylaxis with regards to post-operative risk of venous thromboembolism or bleeding. Sole use of aspirin for venous thromboembolism prophylaxis after total hip arthroplasty should be considered in the appropriate patient.

The contribution of real-world evidence to cost-effectiveness analysis: case study of Dabigatran etexilate in France

OBJECTIVE

The goal of this study was to assess the differences between an ex ante and an ex post cost-effectiveness analysis of Dabigatran etexilate vs VKAs for the prevention of thromboembolic events in non-valvular atrial fibrillation patients and to draw lessons on the design and use of real-world data for decision making.

METHODS

The same model was used to calculate the cost-effectiveness ratio using two sets of parameters. One set included the efficacy and safety outcomes data from RE-LY, the pivotal trial comparing Dabigatran to warfarin; cost data came from an ex ante publication. Outcomes data for the second set came from real-world data studies. Cost data were a mix of real-world data and other sources. Two treatment strategies were compared: treatment initiation by either Dabigatran or VKAs, followed by either VKAs or Dabigatran. A crude comparison of results was performed; the impact of data differences was then assessed. Probabilistic sensitivity results of the two analyses were compared.

RESULTS

With real-world evidence, Dabigatran at both dosages was more effective for the prevention of ischemic strokes, intra-cranial haemorrhages, with less major extra-cranial haemorrhages and a similar risk of myocardial infarction. Using clinical trial data, Dabigatran150 mg (resp. Dabigatran110 mg) as a first-line treatment vs VKAs yielded an ICER of € 8077/QALY (resp. € 13,116/QALY). Real-world evidence scenarios were cost-saving and more effective for both dosages.

CONCLUSION

The reassessment of outcomes and cost data had an impact on results, improving the efficiency of Dabigatran. We identify methodological issues which should be discussed if post-launch RWE based cost-effectiveness data become a standard in HTA decision making.

Cost-effectiveness of apixaban for stroke prevention in non-valvular atrial fibrillation in Saudi Arabia

BACKGROUND

Apixaban, an oral anticoagulant for stroke and systemic embolism prevention in non-valvular atrial fibrillation (NVAF), was superior to warfarin in prevention of stroke and systemic embolism, bleeding outcomes and mortality (ARISTOTLE trial), and substantially reduced stroke risk, with no significant increase in major or intracranial bleeding risk versus aspirin (AVERROES trial).

OBJECTIVE

Estimate cost-effectiveness of apixaban versus other anticoagulants for NVAF treatment in Saudi Arabia.

DESIGN

Lifetime Markov model.

SETTING

A published model was adapted from the United Kingdom (UK) to the Saudi Arabia setting.

PATIENTS AND METHODS

The model enabled pairwise comparisons of apixaban against other anticoagulants, aspirin, and aspirin+clopidogrel. Apart from warfarin and aspirin, comparisons were indirect. Subpopulations included vitamin K antagonist (VKA) suitable and unsuitable patients. Medication and physician visit costs were from published lists. A cost ratio (0.533), from comparison of UK and Saudi physician visit costs, was applied to UK model inputs to estimate local event costs. Background life expectancy was from Saudi life tables. Model structure, treatment comparators, patient characteristics, event rates, and utilities were unchanged. Costs and health benefits were discounted by 3.5% annually.

MAIN OUTCOME MEASURE

Incremental cost-effectiveness ratio of cost per quality-adjusted life-year (QALY) gained.

SAMPLE SIZE

Model cohort of 1000 NVAF patients, for VKA suitable and VKA unsuitable populations.

RESULTS

Apixaban was dominant versus warfarin (VKA suitable) and rivaroxaban (VKA suitable and unsuitable). Compared against dabigatran (110mg, 150 mg, 110/150mg), the cost/QALY gained for apixaban was $5166, $11 143, $10 849 (VKA suitable) and $5 157, $14 424, $14 134 (VKA unsuitable), respectively. Cost/QALY for apixaban versus aspirin and aspirin+clopidogrel was $14 805 and $5784 (VKA suitable); and $10 564 and $4203 (VKA unsuitable), respectively. Sensitivity analyses demonstrated consistency of findings across varying inputs.

CONCLUSIONS

Apixaban was found to be cost-effective for stroke prevention among Saudi NVAF patients, when assessed using a US$20 000 willingness-to-pay threshold.

LIMITATIONS

Lack of robust local clinical, cost and utility data for model inputs. Lack of head-to-head clinical trial data for rivaroxaban, dabigatran, and clopidogrel plus aspirin comparators.

CONFLICT OF INTEREST

Study was funded by Pfizer Inc. and Bristol Myers-Squibb. KO, RS, SAK and AAA received salaries from their respective employers, but did not receive direct financial compensation for participation in or authorship of this study.

Clinical and Cost Effectiveness of Apixaban Compared to Aspirin in Patients with Atrial Fibrillation: An Australian Perspective

OBJECTIVE

To determine the clinical and cost effectiveness of apixaban compared to aspirin in the prevention of thromboembolic events for patients with atrial fibrillation for whom vitamin K antagonist (VKA) therapy (warfarin) has been considered unsuitable.

METHODS

A previously published Markov model with yearly cycles was updated. Information from the Apixaban Versus Acetylsalicylic acid to prevent Stroke in Atrial Fibrillation (AVERROES) trial in combination with other population data was used to simulate the costs and effects of apixaban compared to aspirin over 10 years. The model comprised five health states. Costs from an Australian healthcare perspective were estimated from published sources for the year 2015. The main outcome of interest was number needed to treat (NNT), number needed to harm (NNH), the incremental cost-effectiveness ratio (ICER) [cost per quality-adjusted life-year (QALY) gained, and cost per year of life saved (YoLS)]. Costs and benefits were discounted at 5.0 % per annum.

RESULTS

For each patient followed up over 10 years, NNT to prevent one additional event (thromboembolic event, death) for apixaban compared to aspirin was 4.6 and 11.8, respectively. NNH was 35.9 for non-fatal major bleeding. The model predicted that compared to aspirin, apixaban would lead to 0.33 YoLS (discounted) and 0.29 QALYs gained (discounted), at an incremental cost of AUD$1996 (discounted). This resulted in ICERs of AUD$6011 per YoLS and AUD$6929 per QALY gained. In the sensitivity analyses, ICERs were most sensitive to efficacy measures derived from the AVERROES study, and time frame.

CONCLUSION

Compared to aspirin, apixaban is likely to be cost effective in preventing thromboembolic disease among VKA unsuitable patients with atrial fibrillation.

Cost-effectiveness of Apixaban for Stroke Prevention in Patients with Atrial Fibrillation in Algeria

Background: Atrial fibrillation (AF) is a chronic sustained heart rhythm disorder associated with an increased risk of stroke. Apixaban, a new oral anticoagulant, was approved by the European Medicines Agency for prevention of stroke in patients with AF. The efficacy of apixaban has been investigated in randomised controlled trials. Objectives: The objective of this study was to estimate the economic implications of using apixaban compared to other anti-coagulations to reduce the risk of stroke in patients with AF from the perspective of the Algerian payer. Methods: A previously published Markov model was adapted to the Algerian setting. The model included patients for whom vitamin K antagonist (VKA) treatment is suitable and could initiate on acenocoumarol, rivaroxaban or apixaban, and those unsuitable for VKA treatment who could initiate on aspirin or apixaban. Over a lifetime time horizon, costs were estimated in Algerian dinars (DZD) and outcomes included life-years (LYs), quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios (ICERs). Results: In the VKA suitable population, apixaban was estimated to be a dominant treatment option over rivaroxaban, providing a higher number of QALYs at lower costs, while when compared with acenocoumarol, an ICER of 3 672 059 DZD per QALY gained was estimated. Amongst those unsuitable for VKA therapy, the ICER was 2 061 863 DZD per QALY gained. Conclusion: Apixaban was found to be a cost-effective choice for stroke prevention in patients with AF in Algeria compared to acenocoumarol and rivaroxaban in the VKA suitable population and compared to aspirin in the VKA unsuitable population.

Cost Effectiveness of Apixaban versus Warfarin or Aspirin for Stroke Prevention in Patients with Atrial Fibrillation: A Greek Perspective

BACKGROUND

Strokes attributed to atrial fibrillation (AF) represent a major cause of adult disability and a great burden to society and healthcare systems.

OBJECTIVES

Our objective was to assess the cost effectiveness of apixaban, a direct acting oral anticoagulant (DOAC), versus warfarin or aspirin for patients with AF in the Greek healthcare setting.

METHODS

We used a previously published Markov model to simulate clinical events for patients with AF treated with apixaban, the vitamin K antagonist (VKA) warfarin, or aspirin. Clinical events (ischemic and hemorrhagic stroke, intracranial hemorrhage, other major bleed, clinically relevant non-major bleed, myocardial infarction, and cardiovascular [CV] hospitalizations) were modeled using efficacy data from the ARISTOTLE and AVERROES clinical trials. The cohort's baseline characteristics also sourced from these trials. Among VKA-suitable patients, 64.7% were men with a mean age of 70 years and average CHADS₂ (cardiac failure, hypertension, age, diabetes, stroke₂) score of 2.1, whereas 58.5% of VKA-unsuitable patients were men with a mean age of 70 years and a CHADS₂ score of 2.0. A panel of experts (cardiologists and internists) provided information on the resource use associated with the management of AF. Cost calculations reflect the local clinical setting and a third-party payer perspective (€, discounted at 3%).

RESULTS

Based on a simulation of 1000 VKA-suitable patients over a lifetime horizon, the use of apixaban versus warfarin resulted in 26 fewer strokes and systemic embolisms in total, 65 fewer bleeds, 41 fewer myocardial infarctions, and 29 fewer CV-related deaths, with an incremental cost-effectiveness ratio (ICER) of €14,478/quality-adjusted life-year (QALY). For VKA-unsuitable patients, apixaban versus aspirin resulted in 72 fewer strokes and systemic embolisms and 57 fewer CV-related deaths, with an ICER of €7104/QALY. Sensitivity analyses indicated that results were robust.

CONCLUSIONS

Based on the present analysis, apixaban represents a cost-effective treatment option versus warfarin and aspirin for the prevention of stroke in patients with AF from a Greek healthcare payer perspective over a lifetime horizon.

A Systematic Literature Review on the Cost-Effectiveness of Apixaban for Stroke Prevention in Non-valvular Atrial Fibrillation

INTRODUCTION

Economic evaluations are becoming increasingly important due to limitations in economic resources, the expense of many new treatments, the need to allocate health spending as effectively as possible, and the need to inform decision makers. Based on the data from the apixaban studies (ARISTOTLE and AVERROES), several economic evaluations have been performed in various countries to demonstrate the efficacy of apixaban versus warfarin and aspirin or other new oral anticoagulants (NOACs) for preventing stroke in patients with non-valvular atrial fibrillation (NVAF).The aim of this study was to perform a systematic literature review of published economic evaluations with apixaban in the indication of stroke prevention in patients with NVAF.

METHODS

A search in PubMed, Cochrane Library, Google Scholar, and Index Medicus Español was conducted in June 2015. Inclusion and exclusion criteria were established. The main characteristics were recorded for all relevant articles after being reviewed. In addition, a weighted version of the Drummond's checklist was used to further assess the quality of the selected studies.

RESULTS

After review, 26 cost-effectiveness analyses through Markov models were included; the identified economic evaluations represent different willingness-to-pay (WTP) thresholds, discount rates, medical costs, and healthcare systems. Apixaban was compared with warfarin/acenocoumarol in 7 of them (27%), with warfarin/NOACs in 14 (54%), with aspirin in 2 (8%), and with warfarin/aspirin in 3 (11%). Models were conducted from Europe (69%), USA (23%), Australia (4%), and Latin America (4%). All models reported cost/quality-adjusted life years (QALYs) gained, 92% reported using a payer perspective, and 8% using a societal perspective; the median quality score of the selected studies was 89 (out of 119), with a range of 55-103. In models performed in Europe, incremental cost-effectiveness ratios (ICERs) of apixaban versus warfarin ranged from €5607/QALY to €57,245/QALY, while ICERs versus aspirin ranged from being dominant to €7334/QALY. In models carried out in the USA, ICERs of apixaban versus warfarin ranged from being dominant to $93,063/QALY.

CONCLUSION

Different cost-effectiveness analyses suggest that apixaban is a cost-effective therapeutic option according to the WTP thresholds used in countries where cost-effectiveness analyses, were performed.

FUNDING

BMS and Pfizer.

Cost-effectiveness of apixaban vs. other new oral anticoagulants for the prevention of stroke: an analysis on patients with non-valvular atrial fibrillation in the Greek healthcare setting

BACKGROUND AND OBJECTIVES

Three new oral anticoagulants (NOACs) are currently approved for stroke prevention and systemic embolism in patients with non-valvular atrial fibrillation (NVAF). The objective of this analysis was to assess the cost effectiveness of apixaban against other NOACs for the prevention of stroke in patients with NVAF in Greece.

METHODS

A Markov model that evaluated clinical events, quality-adjusted life expectancy, and costs for patients treated with apixaban or other NOACs formed the basis of the analysis. Clinical events were modeled for a lifetime horizon, based on clinical efficacy data from an indirect comparison, using the ARISTOTLE, ROCKET-AF, and RE-LY clinical trials. Resource use associated with patient monitoring was elicited via a panel of experts (cardiologists and internists). Cost calculations reflect the local clinical setting and followed a third-party payer perspective (Euros, discounted at 3 %).

RESULTS

Apixaban was projected to reduce the occurrence of clinical events and increase quality-adjusted life expectancy and incremental costs of treatment compared with other NOACs. Taking into account costs of medications, patient monitoring, and management of events, the incremental cost-effectiveness ratios for apixaban 5 mg twice daily vs. dabigatran 110 mg twice daily, dabigatran 150 mg twice daily, and rivaroxaban 20 mg once daily were estimated at €9907/quality-adjusted life-year (QALY), €13,727/QALY, and €6936/QALY gained, respectively. Extensive sensitivity analyses indicated that results were robust over a wide range of inputs.

CONCLUSIONS

Based on the results of this analysis, apixaban can be a cost-effective alternative to other NOACs for the prevention of stroke in patients with NVAF in Greece.