1
|
Aebersold H, Foster-Witassek F, Aeschbacher S, Beer JH, Blozik E, Blum M, Bonati L, Conte G, Coslovsky M, De Perna ML, Di Valentino M, Felder S, Huber CA, Moschovitis G, Mueller A, Paladini RE, Reichlin T, Rodondi N, Stauber A, Sticherling C, Szucs TD, Conen D, Kuhne M, Osswald S, Schwenkglenks M, Serra-Burriel M. Patients on vitamin K treatment: is switching to direct-acting oral anticoagulation cost-effective? A target trial on a prospective cohort. Open Heart 2024; 11:e002567. [PMID: 38302139 PMCID: PMC10831440 DOI: 10.1136/openhrt-2023-002567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 01/18/2024] [Indexed: 02/03/2024] Open
Abstract
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.
Collapse
Affiliation(s)
- Helena Aebersold
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | | | - Stefanie Aeschbacher
- Cardiology Division, Department of Medicine, University Hospital Basel, Basel, Switzerland
- Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland
| | - Juerg H Beer
- Department of Medicine, Cantonal Hospital of Baden, Baden, Switzerland
- Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Eva Blozik
- Institute of Primary Care, University of Zurich, Zurich, Switzerland
| | - Manuel Blum
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Leo Bonati
- Department of Neurology, University Hospital Basel, Basel, Switzerland
- Research Department, Reha Rheinfelden, Rheinfelden, Switzerland
| | - Giulio Conte
- Division of Cardiology, Cardiocentro Ticino (CCT), Lugano, Switzerland
| | - Michael Coslovsky
- Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland
- Clinical Trial Unit Basel, Department of Clinical Research, University Hospital Basel, Basel, Switzerland
| | - Maria Luisa De Perna
- Division of Cardiology, Istituto Cardiocentro Ticino, Ospedale Regionale di Bellinzona, Bellinzona, Switzerland
| | - Marcello Di Valentino
- Division of Cardiology, Istituto Cardiocentro Ticino, Ospedale Regionale di Bellinzona, Bellinzona, Switzerland
| | - Stefan Felder
- Faculty of Business and Economics, University of Basel, Basel, Switzerland
| | - Carola A Huber
- Department of Health Sciences, Helsana Group, Zurich, Switzerland
| | - Giorgio Moschovitis
- Division of Cardiology, Ente Ospedaliero Cantonale (EOC), Istituto Cardiocentro Ticino, Ospedale Regionale di Lugano, Lugano, Switzerland
| | - Andreas Mueller
- Department of Cardiology, Triemli Hospital Zurich, Zurich, Switzerland
| | - Rebecca E Paladini
- Cardiology Division, Department of Medicine, University Hospital Basel, Basel, Switzerland
- Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland
| | - Tobias Reichlin
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nicolas Rodondi
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Annina Stauber
- Department of Cardiology, Triemli Hospital Zurich, Zurich, Switzerland
| | - Christian Sticherling
- Cardiology Division, Department of Medicine, University Hospital Basel, Basel, Switzerland
- Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland
| | - Thomas D Szucs
- Health Economics Facility, Department of Public Health, University of Basel, Basel, Switzerland
| | - David Conen
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Michael Kuhne
- Cardiology Division, Department of Medicine, University Hospital Basel, Basel, Switzerland
- Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland
| | - Stefan Osswald
- Cardiology Division, Department of Medicine, University Hospital Basel, Basel, Switzerland
- Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland
| | - Matthias Schwenkglenks
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
- Health Economics Facility, Department of Public Health, University of Basel, Basel, Switzerland
| | - Miquel Serra-Burriel
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| |
Collapse
|
2
|
Li Y, Chen P, Wang X, Peng Q, Xu S, Ma A, Li H. Methods for Economic Evaluations of Novel Oral Anticoagulants in Patients with Atrial Fibrillation: A Systematic Review. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2024; 22:33-48. [PMID: 37898954 DOI: 10.1007/s40258-023-00842-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/08/2023] [Indexed: 10/31/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) is a severe epidemiological and public health concern among the elderly population worldwide, with substantial economic and social burdens. Economic evaluations can play an essential role in optimizing the utilization of scarce resources. In recent years, the number of economic evaluation studies related to AF has increased due to the rising number of AF patients, the continuous updating of clinical data, and the emergence of real-world evidence. However, there are still deficiencies in model settings and parameter sources in relevant studies. OBJECTIVE This study aims to review the existing economic evaluations of novel oral anticoagulants (NOACs) in patients with AF and summarize the evidence and methods applied. METHODS A comprehensive and systematic search was conducted on electronic databases, including PubMed, Embase, Web of Science (WOS), and The Cochrane Library, from the date of database creation to November 2022. The reporting quality of included literature was assessed using the Consolidated Health Economic Evaluation Reporting Standards 2022 (CHEERS 2022) statement. RESULTS A total of 102 studies were included in the review, with 200 comparisons between NOACs and vitamin K antagonists (VKAs), as well as 58 comparisons between different NOACs. The healthcare sector and payer perspectives were the most common, and accordingly, the majority of the evaluations considered only direct medical costs. Most studies used Markov cohort models with the number of health states ranging from 4 to 29. Of included studies, 80 (78%) considered event recurrence and complications, and 78 (76%) considered discontinuation and second-line therapy. All of the studies applied uncertainty analysis to explore the robustness of the results. Of all 200 NOACs-VKAs comparisons, 149 (75%) showed that NOACs were more cost-effective; this proportion was 84% (139 out of 165) in high-income countries but decreased to 29% (10 out of 35) in middle- and low-income countries. Most (82%) of the 28 items in the CHEERS 2022 checklist were elucidated in the majority of included studies. A minority (only 39%) of included studies demonstrated high reporting quality. CONCLUSION NOACs may be more cost-effective than VKAs in patients with AF, but this conclusion applies to high-income countries, whereas VKAs may be more cost-effective in middle- and low-income countries. The reporting quality of included studies was variable, and certain methodological issues were presented. This study highlights the economic evaluation methodology of NOACs in patients with AF and provides recommendations for modeling methods and future studies.
Collapse
Affiliation(s)
- Yan Li
- School of International Pharmaceutical Business, China Pharmaceutical University, No. 639 Longmian Avenue, Nanjing, 211198, Jiangsu, China
- Center for Pharmacoeconomics and Outcomes Research, China Pharmaceutical University, Nanjing, China
| | - Pingyu Chen
- School of International Pharmaceutical Business, China Pharmaceutical University, No. 639 Longmian Avenue, Nanjing, 211198, Jiangsu, China
- Center for Pharmacoeconomics and Outcomes Research, China Pharmaceutical University, Nanjing, China
| | - Xintian Wang
- School of International Pharmaceutical Business, China Pharmaceutical University, No. 639 Longmian Avenue, Nanjing, 211198, Jiangsu, China
- Center for Pharmacoeconomics and Outcomes Research, China Pharmaceutical University, Nanjing, China
| | - Qian Peng
- School of International Pharmaceutical Business, China Pharmaceutical University, No. 639 Longmian Avenue, Nanjing, 211198, Jiangsu, China
- Center for Pharmacoeconomics and Outcomes Research, China Pharmaceutical University, Nanjing, China
| | - Shixia Xu
- School of Pharmacy, Wannan Medical College, Wuhu, China
| | - Aixia Ma
- School of International Pharmaceutical Business, China Pharmaceutical University, No. 639 Longmian Avenue, Nanjing, 211198, Jiangsu, China.
- Center for Pharmacoeconomics and Outcomes Research, China Pharmaceutical University, Nanjing, China.
| | - Hongchao Li
- School of International Pharmaceutical Business, China Pharmaceutical University, No. 639 Longmian Avenue, Nanjing, 211198, Jiangsu, China.
- Center for Pharmacoeconomics and Outcomes Research, China Pharmaceutical University, Nanjing, China.
| |
Collapse
|
3
|
Hallinen T, Soini E, Asseburg C, Linna M, Eloranta P, Sintonen S, Kosunen M. Cost-Effectiveness of Apixaban versus Other Direct Oral Anticoagulants and Warfarin in the Prevention of Thromboembolic Complications Among Finnish Patients with Non-Valvular Atrial Fibrillation. CLINICOECONOMICS AND OUTCOMES RESEARCH 2021; 13:745-755. [PMID: 34413661 PMCID: PMC8370583 DOI: 10.2147/ceor.s317078] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 07/19/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose Direct oral anticoagulant (DOAC) use for the prevention of thromboembolic complications in patients with non-valvular atrial fibrillation (AF) has increased steadily in Finland. DOACs have been shown to be cost-effective in comparison to warfarin, but published evidence of relative cost-effectiveness between DOACs is still scarce and mostly based on indirect comparisons of clinical trial evidence. The aim of this study was to compare the cost-effectiveness of apixaban to dabigatran, rivaroxaban and warfarin in a Finnish setting using real-life evidence where available. Patients and Methods A lifetime Markov simulation model used previously in a published Finnish assessment comparing apixaban and warfarin was modified and updated with the relative effectiveness and safety data available from the real-world NAXOS-study and representative Finnish input data for patient characteristics, event risks, mortality, resource use, costs, and quality of life. Apixaban’s cost-effectiveness was assessed from health care payer perspective (using 3% per year discount rate) based on incremental cost-effectiveness ratio (ICER, cost per quality-adjusted life year [QALY] gained), probability of cost-effectiveness (at willingness-to-pay [WTP] of 35,000 euros/QALY), and net monetary benefit (NMB). Results Apixaban increased the average modelled quality-adjusted life-expectancy and reduced the average total health care costs of AF patients when compared to warfarin (+0.14 QALYs, −3691 euros), dabigatran (+0.11 QALYs, −404 euros), and rivaroxaban (+0.03 QALYs, −43 euros). The resulting NMB of apixaban versus warfarin, dabigatran and rivaroxaban was 8723, 4168, and 1129 euros, respectively. The respective probabilities of apixaban being cost-effective against each comparator were 100%, 92.7%, and 64.0%. Conclusion In this modelling study, apixaban dominated other anticoagulants in the Finnish real-life setting.
Collapse
Affiliation(s)
| | | | | | - Miika Linna
- Aalto University, Department of Industrial Engineering and Management, Espoo, Finland
| | | | | | | |
Collapse
|
4
|
Fang W, Wang Z, Giles MB, Jackson CH, Welton NJ, Andrieu C, Thom H. Multilevel and Quasi Monte Carlo Methods for the Calculation of the Expected Value of Partial Perfect Information. Med Decis Making 2021; 42:168-181. [PMID: 34231446 PMCID: PMC8777326 DOI: 10.1177/0272989x211026305] [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] [Indexed: 11/16/2022]
Abstract
The expected value of partial perfect information (EVPPI) provides an upper bound
on the value of collecting further evidence on a set of inputs to a
cost-effectiveness decision model. Standard Monte Carlo estimation of EVPPI is
computationally expensive as it requires nested simulation. Alternatives based
on regression approximations to the model have been developed but are not
practicable when the number of uncertain parameters of interest is large and
when parameter estimates are highly correlated. The error associated with the
regression approximation is difficult to determine, while MC allows the bias and
precision to be controlled. In this article, we explore the potential of quasi
Monte Carlo (QMC) and multilevel Monte Carlo (MLMC) estimation to reduce the
computational cost of estimating EVPPI by reducing the variance compared with MC
while preserving accuracy. We also develop methods to apply QMC and MLMC to
EVPPI, addressing particular challenges that arise where Markov chain Monte
Carlo (MCMC) has been used to estimate input parameter distributions. We
illustrate the methods using 2 examples: a simplified decision tree model for
treatments for depression and a complex Markov model for treatments to prevent
stroke in atrial fibrillation, both of which use MCMC inputs. We compare the
performance of QMC and MLMC with MC and the approximation techniques of
generalized additive model (GAM) regression, Gaussian process (GP) regression,
and integrated nested Laplace approximations (INLA-GP). We found QMC and MLMC to
offer substantial computational savings when parameter sets are large and
correlated and when the EVPPI is large. We also found that GP and INLA-GP were
biased in those situations, whereas GAM cannot estimate EVPPI for large
parameter sets.
Collapse
Affiliation(s)
- Wei Fang
- Mathematical Institute, University of Oxford, Oxford, Oxfordshire, UK
| | - Zhenru Wang
- Mathematical Institute, University of Oxford, Oxford, Oxfordshire, UK
| | - Michael B Giles
- Mathematical Institute, University of Oxford, Oxford, Oxfordshire, UK
| | - Chris H Jackson
- MRC Biostatistics Unit, University of Cambridge, Cambridge, Cambridgeshire, UK
| | - Nicky J Welton
- Population Health Science, Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Howard Thom
- Population Health Science, Bristol Medical School, University of Bristol, Bristol, UK
| |
Collapse
|
5
|
Wu Y, Zhang C, Gu ZC. Cost-Effectiveness Analysis of Direct Oral Anticoagulants Vs. Vitamin K Antagonists in the Elderly With Atrial Fibrillation: Insights From the Evidence in a Real-World Setting. Front Cardiovasc Med 2021; 8:675200. [PMID: 34268343 PMCID: PMC8275875 DOI: 10.3389/fcvm.2021.675200] [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: 03/02/2021] [Accepted: 05/21/2021] [Indexed: 11/13/2022] Open
Abstract
Background: In the clinical setting, the economic benefits of direct oral anticoagulants (DOACs) in elderly patients with atrial fibrillation (AF) remain unclear. This study aimed to estimate and compare the cost-effectiveness of DOACs (dabigatran, rivaroxaban, apixaban, and edoxaban) and vitamin K antagonists (VKAs; warfarin) in preventing stroke among AF patients aged >75 years in real-world practice. Methods: A Markov model with a 10-year span was constructed to estimate the long-term clinical and economic outcomes among AF patients aged >75 years treated with DOACs and warfarin. The study was populated with a hypothetical cohort of 10,000 AF patients aged >75 years. Probabilities of clinical outcomes were obtained from the pooled observational studies (OSs), comparing DOACs (dabigatran, rivaroxaban, apixaban, and edoxaban) with VKAs. Other model inputs, including the utilities and the costs, were all estimated from public sources and the published literature. The costs, quality-adjusted life-years (QAYLs), and incremental cost-effectiveness ratios (ICER) were estimated for each treatment strategy. Subgroup analyses of individual DOACs and the scenario analysis were performed. Uncertainty was evaluated by deterministic sensitivity analysis and probabilistic sensitivity analysis (PSA). Results: Compared to warfarin, DOACs were associated with a gain of 0.36 QALY at an additional cost of $15,234.65, resulting in an ICER of $42,318.47 per QALY. Sensitivity analysis revealed that the ICER was sensitive to the cost of DOACs. Direct oral anticoagulants also shifted from dominating to dominated status When their annual costs of DOACs were over $3,802.84 or the risk ratio of death compared to warfarin was over 1.077%/year. Probabilistic sensitivity analysis (PSA) suggested that DOACs had a 53.83 and 90.7% probability of being cost-effective when the willingness-to-pay threshold was set at $50,000 and $100,000, respectively. Among all the four individual DOACs, edoxaban treatment was revealed as the preferred treatment strategy for the AF patients aged over 75 years by yielding the most significant health gain with the relatively low total cost. Conclusions: Despite the high risk for major bleeding in elderly patients with AF, DOACs are more cost-effective treatment options than warfarin in real-world practice. Edoxaban was the preferred treatment strategy among four kinds of DOACs for AF patients aged over 75 years. Furthermore, beyond their safety profiles, the treatment benefits of DOACs assumed greater relevance and importance in older adults.
Collapse
Affiliation(s)
- Yue Wu
- Department of Pharmacy, Renmin Hospital, Wuhan University, Wuhan, China.,School of Pharmaceutical Sciences, Wuhan University, Wuhan, China
| | - Chi Zhang
- Department of Pharmacy, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,School of Medicine, Tongji University, Shanghai, China.,Shanghai Anticoagulation Pharmacist Alliance, Shanghai Pharmaceutical Association, Shanghai, China
| | - Zhi-Chun Gu
- Department of Pharmacy, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Anticoagulation Pharmacist Alliance, Shanghai Pharmaceutical Association, Shanghai, China.,Chinese Society of Cardiothoracic and Vascular Anesthesiology, Beijing, China
| |
Collapse
|
6
|
Uptake of direct oral anticoagulants in primary care: an ecological and economic study. BJGP Open 2020; 4:bjgpopen20X101033. [PMID: 32430303 PMCID: PMC7330214 DOI: 10.3399/bjgpopen20x101033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 10/24/2019] [Indexed: 12/25/2022] Open
Abstract
Background Clinical trials indicate that direct oral anticoagulants (DOACs) are as effective as warfarin at preventing ischaemic stroke. It is unclear, however, whether relative changes in DOAC uptake have affected clinical and economic outcomes in practice. Aim To investigate variations in DOAC uptake and the relationship with hospital admissions and cost. Design & setting An ecological study using electronic administrative records from England, April 2012 to March 2017. Method Multivariable regression was used to model practice variation in DOAC prescribing, and the relationship with clinical and economic outcomes. Results In quarter 1 of 2017, 55.0% of the 2 695 262 patients dispensed an anticoagulant were given a DOAC. There was a two-fold difference in odds of dispensing DOACs between clinical commissioning groups (CCGs) between those with the highest and lowest usage of these drugs. Increases in the relative uptake of DOACs were not associated with hospital admissions for ischaemic stroke (adjusted incidence rate ratio [IRR] = 1.00; 95% confidence intervals [CI] = 0.999 to 1.001), nor gastrointestinal or intracranial bleeds (IRR = 1.001; 95% CI = 1.000 to 1.002). In 2017, quarter 1, CCGs spent £9247 (inter-quartile range £7751 to £10 853) per 1000 patients on anticoagulants. The marginal effect of a 5% increase in DOAC uptake was associated with a £17.95 (£8.75 to £27.15) increase in total costs, per 1000 patient population. Conclusion There were significant differences in the relative uptake of DOACs across practices, with greater costs but no reduction in hospital admissions in those with higher levels of dispensing. Findings indicate that clinical and economic benefits of DOACs identified by clinical trials are not realised in practice.
Collapse
|