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Wu Y, Yin T, Jian G, Wan T, Zhou B. Cost-effectiveness analysis of direct oral anticoagulants versus low-molecular-weight heparin and no thromboprophylaxis in primary prevention of cancer-associated venous thromboembolism in China. Front Pharmacol 2024; 15:1373333. [PMID: 39376608 PMCID: PMC11456474 DOI: 10.3389/fphar.2024.1373333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 08/19/2024] [Indexed: 10/09/2024] Open
Abstract
Background and objective Cancer-associated venous thromboembolism (CAVTE) is a preventable, life-threatening complication with a considerable morbidity and mortality. Primary venous thromboembolism (VTE) prophylaxis is currently recommended; however, the health and economic benefits have not been evaluated and compared in China. This study aimed to assess and compare the cost-effectiveness of anticoagulants in primary CAVTE prevention among cancer patients in China. Methods A Markov model with a 5-year horizon was established to evaluate the costs and effectiveness of direct oral anticoagulants (DOACs) compared to low-molecular-weight heparins (LMWHs) and no prevention in primary prophylaxis of CAVTE in China. Key clinical outcomes were obtained from the available clinical trials, comparing DOACs (rivaroxaban and apixaban) with LMWHs or with no thromboprophylaxis. Utility and the cost inputs were all obtained from the published literature or local data with public sources. The total costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs) were estimated as the main endpoints of the modal for each strategy. The assessment of uncertainty was performed involving deterministic sensitivity analysis and probabilistic sensitivity analysis (PSA). Impact of time horizon, generic drug price, and individual DOACs were assessed in scenario and subgroup analyses. Results Primary prophylaxis using DOACs were projected to yield 1.866 QALYs at a cost of $3,287.893, resulting in the ICERs of $12,895.851 (DOACs vs. no-thromboprophylaxis) and $43,613.184/QALYs (LMWHs vs. DOACs). Sensitivity analysis revealed that ICER was sensitive to the VTE and bleeding risk, drug cost of anticoagulants, self-payment ratio, and overall death rate of cancer. Probabilistic sensitivity analysis showed that DOACs and LMWHs had a 48% and 45% probability of being cost-effective at a 5-year time horizon, respectively. When the time horizon extended to 10 years, DOACs achieved a cost-effective probability of 43%. Among individual DOACs, apixaban was found to be the preferred strategy in VTE prevention due to its incremental health gain with an acceptable cost increase. Conclusion Primary thromboprophylaxis with DOACs was cost-effective in cancer patients at a willing-to-pay (WTP) threshold of $37,125.24/QALY in China. Cancer death rate, risk of VTE and major bleeding, and the drug cost assumed greater relevance and importance in the decision-making process for primary thromboprophylaxis in cancer.
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Affiliation(s)
- Yue Wu
- Department of Pharmacy, Renmin Hospital, Wuhan University, Wuhan, China
- School of Pharmaceutical Sciences, Wuhan University, Wuhan, China
| | - TianChen Yin
- Department of Pharmacy, Renmin Hospital, Wuhan University, Wuhan, China
- School of Pharmaceutical Sciences, Wuhan University, Wuhan, China
| | - GuiLin Jian
- Department of Pharmacy, Renmin Hospital, Wuhan University, Wuhan, China
- School of Pharmaceutical Sciences, Wuhan University, Wuhan, China
| | - Tao Wan
- Department of Pharmacy, Renmin Hospital, Wuhan University, Wuhan, China
- School of Pharmaceutical Sciences, Wuhan University, Wuhan, China
- Department of Pharmacy, Changzhou Jintan District Hospital of Traditional Chinese Medicine, Changzhou, China
| | - Benhong Zhou
- Department of Pharmacy, Renmin Hospital, Wuhan University, Wuhan, China
- School of Pharmaceutical Sciences, Wuhan University, Wuhan, China
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Kang W, Peng K, Yan VK, Al-Badriyeh D, Lee SF, Yiu HHE, Wei Y, Li STH, Ye X, El Helali A, Lam KO, Lee VHF, Wong ICK, Chan EW. Direct oral anticoagulants versus low-molecular-weight heparin in patients with cancer-associated venous thrombosis: a cost-effectiveness analysis. J Pharm Policy Pract 2024; 17:2375269. [PMID: 39027009 PMCID: PMC11257015 DOI: 10.1080/20523211.2024.2375269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 06/25/2024] [Indexed: 07/20/2024] Open
Abstract
Background Direct oral anticoagulants (DOACs) have demonstrated clinical benefits and better patient adherence over low-molecular-weight heparin (LMWH) in treating patients with cancer-associated venous thrombosis (CAT). We aimed to compare the cost-effectiveness of DOACs against LMWH in patients with CAT from the perspective of the Hong Kong healthcare system. Methods A Markov state-transition model was performed to estimate the incremental cost-effectiveness ratio (ICER) per quality-adjusted life years (QALYs) for DOACs and LMWH in a hypothetical cohort of 10,000 patients with CAT over a 5-year lifetime horizon. The model was primarily based on the health states of no event, recurrent venous thromboembolism, bleeding, and death. Transition probabilities, relative risks, and utilities were derived from the literature. Resource cost data were obtained from the Hong Kong Hospital Authority. Deterministic and probabilistic sensitivity analyses tested the robustness of the results. Results Relative to LMWH, DOACs were associated with increased QALYs (1.52 versus 1.50) at a lower medical cost of USD 2,232 versus 8,224 in five years. The cost of LMWH was the main contributor to the outcome. Out of 10,000 simulated cases, DOACs were dominant in 15.8% and cost-effective in 42.1%, at the willingness-to-pay threshold of USD 148,392 per additional QALY. Conclusions DOACs were associated with greater QALY improvements and lower overall costs compared to LMWH. Accounting for uncertainty, DOACs were between cost-effective and dominant in 57.9% of cases. DOACs are a cost-effective alternative to LMWH in the management of CAT in Hong Kong.
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Affiliation(s)
- Wei Kang
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, People’s Republic of China
| | - Kuan Peng
- Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, People’s Republic of China
| | - Vincent K.C. Yan
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, People’s Republic of China
| | | | - Shing Fung Lee
- Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore, Singapore
| | - Hei Hang Edmund Yiu
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, People’s Republic of China
| | - Yue Wei
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, People’s Republic of China
| | - Silvia T. H. Li
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, People’s Republic of China
| | - Xuxiao Ye
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, People’s Republic of China
| | - Aya El Helali
- Department of Clinical Oncology, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, People’s Republic of China
| | - Ka On Lam
- Department of Clinical Oncology, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, People’s Republic of China
- Clinical Oncology Center, The University of Hong Kong-Shenzhen Hospital, Shenzhen, People’s Republic of China
| | - Victor H. F. Lee
- Department of Clinical Oncology, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, People’s Republic of China
- Clinical Oncology Center, The University of Hong Kong-Shenzhen Hospital, Shenzhen, People’s Republic of China
| | - Ian C. K. Wong
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, People’s Republic of China
- Laboratory of Data Discovery for Health (D4H), Hong Kong Science and Technology Park, Hong Kong SAR, People’s Republic of China
- School of Pharmacy, Aston University, Birmingham, UK
- School of Pharmacy, Medical Sciences Division, Macau University of Science and Technology, Macau SAR, People’s Republic of China
- Department of Pharmacy, The University of Hong Kong-Shenzhen Hospital, Shenzhen, People’s Republic of China
| | - Esther W. Chan
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, People’s Republic of China
- Laboratory of Data Discovery for Health (D4H), Hong Kong Science and Technology Park, Hong Kong SAR, People’s Republic of China
- The University of Hong Kong Shenzhen Institute of Research and Innovation, Shenzhen, People’s Republic of China
- Department of Pharmacy, The University of Hong Kong-Shenzhen Hospital, Shenzhen, People’s Republic of China
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Gulati S, Eckman MH. Anticoagulant Therapy for Cancer-Associated Thrombosis : A Cost-Effectiveness Analysis. Ann Intern Med 2023; 176:1-9. [PMID: 36571839 PMCID: PMC10279520 DOI: 10.7326/m22-1258] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) offer an alternative to low-molecular-weight heparin (LMWH) and warfarin for treating cancer-associated thrombosis (CAT). OBJECTIVE To determine the cost and effectiveness of DOACs versus LMWH. DESIGN Cohort-state transition decision analytic model. DATA SOURCES Network meta-analysis comparing DOACs versus LMWH. TARGET POPULATION Adult patients with cancer at the time they develop thrombosis. TIME HORIZON Lifetime. PERSPECTIVE Health care sector. INTERVENTION Strategies of 1) enoxaparin, 2) apixaban, 3) edoxaban, and 4) rivaroxaban for treatment of CAT. OUTCOME MEASURES Incremental cost-effectiveness ratio (ICER) in 2022 U.S. dollars per quality-adjusted life-year (QALY) gained. RESULTS OF BASE-CASE ANALYSIS In the base-case scenario, using drug prices from the U.S. Department of Veterans Affairs Federal Supply Schedule, apixaban dominated enoxaparin and edoxaban by being less costly and more effective. Rivaroxaban was slightly more effective than apixaban, with an ICER of $493 246. In a scenario analysis using "real-world" drug prices from GoodRx, rivaroxaban was cost-effective with an ICER of $50 053 per QALY. RESULTS OF SENSITIVITY ANALYSIS Results were highly sensitive to monthly drug costs. Probabilistic sensitivity analyses showed that at a willingness-to-pay threshold of $50 000 per QALY, apixaban was preferred in 80% of simulations. However, sensitivity analyses also demonstrated that apixaban only remained cost-effective if monthly medication costs were below $530. Above this, rivaroxaban became cost-effective. LIMITATIONS An assumption was made that patients would continue anticoagulation indefinitely unless they suffered a major bleed. Nonmedical costs such as patient and caregiver loss of productivity were not accounted for, and long-term thrombotic complications were not explicitly modeled. CONCLUSION The 3 DOACs are more effective and more cost-effective than LMWH. The most cost-effective DOAC depends on the relative cost of each of these agents. These are important considerations for treating physicians and health policymakers. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
- Shuchi Gulati
- Division of Hematology and Oncology, Department of Medicine, UC Davis Comprehensive Cancer Center, Sacramento, California (S.G.)
| | - Mark H Eckman
- University of Cincinnati Medical Center, Cincinnati, and Division of General Internal Medicine, University of Cincinnati, Cincinnati, Ohio (M.H.E.)
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Cost-Utility Analysis Comparing Direct Oral Anticoagulant and Low Molecular Weight Heparin Therapies for Secondary Prevention of Cancer-Associated Thrombosis. Clin Drug Investig 2022; 42:1075-1083. [DOI: 10.1007/s40261-022-01217-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/11/2022] [Indexed: 11/03/2022]
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Wumaier K, Li W, Cui J. New Oral Anticoagulants Open New Horizons for Cancer Patients with Venous Thromboembolism. Drug Des Devel Ther 2022; 16:2497-2507. [PMID: 35959418 PMCID: PMC9357558 DOI: 10.2147/dddt.s373726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 07/16/2022] [Indexed: 11/23/2022] Open
Abstract
Venous thromboembolism (VTE) is associated with increased morbidity and mortality, decreased quality of life, and higher economic burden in patients with cancer. Currently, the treatment of VTE in patients with cancer is particularly challenging. For many years, low molecular weight heparin (LMWHs) has been the standard for the treatment of cancer-associated VTE. Recently, the introduction of new oral anticoagulants (NOACs) may offer an oral anticoagulant option for some patients with cancer-associated thrombosis (CAT) as a growing body of literature supports the use of NOACs in the setting of CAT. With the use of NOAC as a new option in the management of CAT, clinicians now face several choices for the individual cancer patient with VTE. We need a more in-depth understanding of the drug properties, efficacy and safety, economic analysis that allows us to choose the most appropriate treatment for each patient. In the review, we will present an overview of CAT management, discuss the available evidence, economic costs for NOACs in the treatment of CAT, and seek to provide the best range of treatments for cancer patients.
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Affiliation(s)
- Kaidireyahan Wumaier
- The First Hospital of Jilin University, Jilin University, Changchun, People’s Republic of China
| | - Wenqian Li
- The First Hospital of Jilin University, Jilin University, Changchun, People’s Republic of China
| | - Jiuwei Cui
- Department of Cancer Center, the First Hospital of Jilin University, Changchun, People’s Republic of China
- Correspondence: Jiuwei Cui, Department of Cancer Center, the First Hospital of Jilin University, Changchun, Jilin, 130021, People’s Republic of China, Tel/Fax +86-0431-88782178, Email
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Wumaier K, Li W, Chen N, Cui J. Direct oral anticoagulants versus low molecular weight heparins for the treatment of cancer-associated thrombosis: a cost-effectiveness analysis. Thromb J 2021; 19:68. [PMID: 34587969 PMCID: PMC8479897 DOI: 10.1186/s12959-021-00319-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 09/05/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Recently, direct oral anticoagulants (DOACs) have been included in guidelines for the treatment of cancer-associated thrombosis (CAT) to be extended to suitable cancer patients. The purpose of this study was to compare the cost-effectiveness of using DOACs and low molecular weight heparins (LMWHs) for treating CAT from the perspective of the Chinese healthcare system. METHODS A Markov model was constructed to estimate the cost-effectiveness of the two strategies with a 6-month and 5-year time horizon. Input parameters were either sourced from the clinical trial, published literature. The primary outcome of the model was reported as incremental cost-effectiveness ratios (ICERs). Sensitivity analyses were performed to test model uncertainty. RESULTS The 6-month cost of DOACs was $ 654.65 with 0.40 quality adjusted life-years (QALYs) while the 6-month cost of LMWHs was $USD 1719.31 with 0.37 QALYs. Similarly, treatment with DOACs had a lower cost ($USD 657.85 vs. $USD 1716.56) and more health benefits (0.40 QALYs vs. 0.37 QALYs) than treatment with LMWHs in a subgroup of patients with gastrointestinal malignancy. We found treatment with DOACs would result in a large reduction in cost ($USD 1447.22 vs. $USD 3374.70) but a small reduction in QALYs (3.07 QALYs vs. 3.09 QALYs) compared with LMWHs over a 5-year time frame, resulting in an ICER of $USD 112895.50/QALYs. Sensitivity analysis confirmed the robustness of the results. CONCLUSION As compared to LMWHs, DOACs can be a cost-saving anticoagulant choice for the treatment of CAT in the general oncology population and gastrointestinal malignancy population.
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Affiliation(s)
| | | | - Naifei Chen
- Department of Cancer center, the First Hospital of Jilin University, Changchun, Jilin, 130021, China
| | - Jiuwei Cui
- Department of Cancer center, the First Hospital of Jilin University, Changchun, Jilin, 130021, China.
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Shah S, Karathanasi A, Revythis A, Ioannidou E, Boussios S. Cancer-Associated Thrombosis: A New Light on an Old Story. Diseases 2021; 9:34. [PMID: 34064390 PMCID: PMC8161803 DOI: 10.3390/diseases9020034] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 04/08/2021] [Accepted: 05/01/2021] [Indexed: 12/12/2022] Open
Abstract
Cancer-associated thrombosis (CAT) is a rising and significant phenomenon, becoming the second leading cause of death in cancer patients. Pathophysiology of CAT differs from thrombosis in the non-cancer population. There are additional risk factors for thrombosis specific to cancer including cancer type, histology, and treatment, such as chemotherapy. Recently developed scoring systems use these risk factors to stratify the degree of risk and encourage thromboprophylaxis in intermediate- to high-risk patients. Anticoagulation is safely used for prophylaxis and treatment of CAT. Both of these have largely been with low-molecular-weight heparin (LMWH), rather than the vitamin K antagonist (VKA); however, there has been increasing evidence for direct oral anticoagulant (DOAC) use. Consequently, international guidelines have also adapted to recommend the role of DOACs in CAT. Using DOACs is a turning point for CAT, but further research is warranted for their long-term risk profile. This review will discuss mechanisms, risk factors, prophylaxis and management of CAT, including both LMWH and DOACs. There will also be a comparison of current international guidelines and how they reflect the growing evidence base.
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Affiliation(s)
- Sidrah Shah
- Department of Hematology/Medical Oncology, Medway NHS Foundation Trust, Windmill Road, Gillingham ME7 5NY, UK; (S.S.); (A.K.); (A.R.)
| | - Afroditi Karathanasi
- Department of Hematology/Medical Oncology, Medway NHS Foundation Trust, Windmill Road, Gillingham ME7 5NY, UK; (S.S.); (A.K.); (A.R.)
| | - Antonios Revythis
- Department of Hematology/Medical Oncology, Medway NHS Foundation Trust, Windmill Road, Gillingham ME7 5NY, UK; (S.S.); (A.K.); (A.R.)
| | - Evangelia Ioannidou
- Department of Paediatrics and Child Health, West Suffolk Hospital NHS Foundation Trust, Hardwick Lane, Bury St Edmunds IP33 2QZ, UK;
| | - Stergios Boussios
- Department of Hematology/Medical Oncology, Medway NHS Foundation Trust, Windmill Road, Gillingham ME7 5NY, UK; (S.S.); (A.K.); (A.R.)
- Faculty of Life Sciences & Medicine, School of Cancer & Pharmaceutical Sciences, King’s College London, London SE1 9RT, UK
- AELIA Organization, 9th Km Thessaloniki-Thermi, 57001 Thessaloniki, Greece
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McDaid D, Park AL. Modelling the Economic Impact of Reducing Loneliness in Community Dwelling Older People in England. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18041426. [PMID: 33546496 PMCID: PMC7913744 DOI: 10.3390/ijerph18041426] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 01/28/2021] [Accepted: 01/30/2021] [Indexed: 01/01/2023]
Abstract
Loneliness has been associated with poor mental health and wellbeing. In England, a 2018 national strategy on loneliness was published, and public health guidelines recommend participation in social activities. In the absence of existing economic evidence, we modelled the potential cost effectiveness of a service that connects lonely older people to social activities against no-intervention. A 5-year Markov model was constructed from a health and social care perspective. Parameters were drawn from the literature, with the intervention structure based on an existing loneliness alleviation programme implemented in several settings across England. Univariate and probabilistic sensitivity analyses were undertaken. The total expected cost per participant in the intervention group is £ 7131 compared to £ 6783 in the usual care group with 0.45 loneliness free years (LFY) gained. The incremental cost per LFY gained is £ 768; in the probabilistic sensitivity analysis the intervention is cost saving in 3.5% of iterations. Potentially such interventions may be cost-effective but are unlikely to be cost-saving even allowing for sustained effects and cumulative adverse health and social care events averted. Empirical studies are needed to determine the cost-effectiveness of these interventions, ideally mapping changes in loneliness to the quality of life, in order to allow the key metric in health economic studies, cost per quality adjusted life year to be estimated.
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