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Lehto M, Luojus A, Halminen O, Haukka J, Putaala J, Linna M, Mustonen P, Kinnunen J, Lehtonen O, Teppo K, Tiili P, Kouki E, Itäinen-Strömberg S, Niemi M, Aro AL, Hartikainen J, Airaksinen KEJ. Time-in-therapeutic-range defined warfarin and direct oral anticoagulants in atrial fibrillation: a Nationwide Cohort Study. Ann Med 2024; 56:2364825. [PMID: 38873855 PMCID: PMC11182072 DOI: 10.1080/07853890.2024.2364825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Accepted: 04/30/2024] [Indexed: 06/15/2024] Open
Abstract
BACKGROUND Little is known how individual time-in-therapeutic-range (TTR) impacts the effectiveness and safety of warfarin therapy compared to direct oral anticoagulants (DOACs) in patients with atrial fibrillation (AF). OBJECTIVE To compare the effectiveness and safety of standard dose DOACs to warfarin in patients with AF, while categorizing warfarin treated patients into quartiles based on their individual TTR. MATERIALS AND METHODS We conducted a nationwide study including all patients with new-onset AF between 2011 and 2018 in Finland. Hazard ratios (HR) were calculated using Cox regression analysis with the inverse probability of treatment weighted method to assess the risks of ischaemic stroke (IS), intracranial haemorrhage (ICH) and mortality for users of apixaban (n = 12,426), dabigatran (n = 4545), rivaroxaban (n = 12,950) and warfarin (n = 43,548). RESULTS The median TTR for warfarin users was 72%. Compared to the second best TTR quartile (reference), the risk of IS was higher in the two poorest TTR quartiles, and lower in the best TTR quartile and on rivaroxaban [2.35 (95% confidence interval, 1.85-2.85), 1.44 (1.18-1.75), 0.60 (0.47-0.77) and 0.72 (0.56-0.92)]. These differences were non-significant for apixaban and dabigatran. HR of ICH was 6.38 (4.88-8.35) and 1.87 (1.41-2.49) in the two poorest TTR groups, 1.44 (1.02-1.93) on rivaroxaban, and 0.58 (0.40-0.85) in the best TTR group compared to the reference group. Mortality was higher in the two poorest TTR groups and lowest in the best TTR group. CONCLUSIONS The outcome was unsatisfactory in the two lowest TTR quartiles - in half of the patients treated with warfarin. The differences between the high TTR groups and standard dose DOACs were absent or modest.
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Affiliation(s)
- Mika Lehto
- Department of Internal Medicine, Jorvi Hospital, HUS Helsinki University Hospital, Helsinki, Finland
- University of Helsinki, Helsinki, Finland
| | | | | | | | - Jukka Putaala
- University of Helsinki, Helsinki, Finland
- Department of Neurology, HUS Helsinki University Hospital, Helsinki, Finland
| | - Miika Linna
- Aalto University, Espoo, Finland
- University of Eastern Finland, Kuopio, Finland
| | - Pirjo Mustonen
- Turku University Hospital, Turku, Finland
- University of Turku, Turku, Finland
| | - Janne Kinnunen
- University of Helsinki, Helsinki, Finland
- Department of Neurology, HUS Helsinki University Hospital, Helsinki, Finland
| | | | - Konsta Teppo
- Turku University Hospital, Turku, Finland
- University of Turku, Turku, Finland
| | - Paula Tiili
- University of Helsinki, Helsinki, Finland
- Department of Neurology, HUS Helsinki University Hospital, Helsinki, Finland
| | - Elis Kouki
- University of Helsinki, Helsinki, Finland
| | - Saga Itäinen-Strömberg
- University of Helsinki, Helsinki, Finland
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
| | - Mikko Niemi
- Department of Clinical Pharmacology and Individualized Drug Therapy Research Program, University of Helsinki, Helsinki, Finland
- Department of Clinical Pharmacology, HUS Diagnostic Center, Helsinki University Hospital, Helsinki, Finland
| | - Aapo L. Aro
- University of Helsinki, Helsinki, Finland
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
| | - Juha Hartikainen
- University of Eastern Finland, Kuopio, Finland
- Heart Center, Kuopio University Hospital, Kuopio, Finland
| | | | - On behalf of the FinACAF Study Group
- Department of Internal Medicine, Jorvi Hospital, HUS Helsinki University Hospital, Helsinki, Finland
- University of Helsinki, Helsinki, Finland
- Aalto University, Espoo, Finland
- Department of Neurology, HUS Helsinki University Hospital, Helsinki, Finland
- University of Eastern Finland, Kuopio, Finland
- Turku University Hospital, Turku, Finland
- University of Turku, Turku, Finland
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
- Department of Clinical Pharmacology and Individualized Drug Therapy Research Program, University of Helsinki, Helsinki, Finland
- Department of Clinical Pharmacology, HUS Diagnostic Center, Helsinki University Hospital, Helsinki, Finland
- Heart Center, Kuopio University Hospital, Kuopio, Finland
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Tajik A, Abbasi A, Goudarzi Z, Izadi‐Moud A, Varmaghani M. Cost-Effectiveness and Budget Impact Analysis of Apixaban and Rivaroxaban Versus Warfarin in the Prevention of Stroke in Patients With Non-Valvular Atrial Fibrillation (NVAF) in Iran. Clin Cardiol 2024; 47:e24311. [PMID: 38923583 PMCID: PMC11194975 DOI: 10.1002/clc.24311] [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: 04/12/2024] [Revised: 05/29/2024] [Accepted: 06/10/2024] [Indexed: 06/28/2024] Open
Abstract
INTRODUCTION This study evaluates the cost-effectiveness of Apixaban and Rivaroxaban, compared to Warfarin, for stroke prevention in patients with non-valvular atrial fibrillation in Iran. METHOD A Markov model with a 30-year time horizon was employed to simulate and assess different treatment strategies' cost-effectiveness. The study population comprised Iranian adults with NVAF, identified through specialist consultations, hospital visits, and archival record reviews. Direct medical costs, direct nonmedical, and indirect costs were included. Quality-adjusted life years (QALY) were assessed using an EQ-5D questionnaire. This study utilized a cost-effectiveness threshold of $11 134 per QALY. RESULTS Apixaban demonstrated superior cost-effectiveness compared to Rivaroxaban and Warfarin. Over 30 years, total costs were lower in the Apixaban and Rivaroxaban groups compared to the Warfarin group ($126.18 and $109.99 vs. $150.49). However, Apixaban showed higher total QALYs gained compared to others (0.134 vs. 0.133 and 0.116). The incremental cost-effectiveness ratio for comparing Apixaban to Warfarin was calculated at -1332.83 cost per QALY, below the threshold of $11 134, indicating Apixaban's cost-effectiveness. Sensitivity analyses confirmed the robustness of the findings, with ICER consistently remaining below the threshold. Over 5 years (2024-2028) of Apixaban usage, the incremental cost starts at USD 70 250 296 in the first year and gradually rises to USD 71 770 662 in the fifth year. DSA and PSA were assessed to prove the robustness of the results. CONCLUSION This study shows that Apixaban is a cost-effective option for stroke prevention in non-valvular atrial fibrillation patients in Iran compared to Warfarin.
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Affiliation(s)
- Amirmohammad Tajik
- School of PharmacyMashhad University of Medical SciencesMashhadIran
- Health Policy Research Center, Institute of HealthShiraz University of Medical SciencesShirazIran
| | - Azam Abbasi
- Department of Management Sciences and Health Economics, School of HealthMashhad University of Medical SciencesMashhadIran
| | - Zahra Goudarzi
- School of Health Management and Information Sciences, Health Human Resources Research CenterShiraz University of Medical SciencesShirazIran
| | - Azadeh Izadi‐Moud
- Department of Cardiovascular Diseases, Faculty of MedicineMashhad University of Medical SciencesMashhadIran
| | - Mehdi Varmaghani
- Social Determinants of Health Research CenterMashhad University of Medical SciencesMashhadIran
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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.
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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.
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Mullen CA. Apixaban for Children With Heart Disease. J Am Coll Cardiol 2023; 82:2310-2311. [PMID: 38057073 DOI: 10.1016/j.jacc.2023.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 10/10/2023] [Indexed: 12/08/2023]
Affiliation(s)
- Craig A Mullen
- Department of Pediatrics, Division of Pediatric Hematology/Oncology and Department of Medicine, Blood and Coagulation Disorders Center, University of Rochester, Rochester, New York, USA.
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Hallinen T, Kivelä S, Soini E, Harjola VP, Pesonen M. Cost-Effectiveness of Empagliflozin in Combination with Standard Care versus Standard Care Only in the Treatment of Heart Failure Patients in Finland. Clinicoecon Outcomes Res 2023; 15:1-13. [PMID: 36636485 PMCID: PMC9831000 DOI: 10.2147/ceor.s391455] [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: 10/10/2022] [Accepted: 12/16/2022] [Indexed: 01/07/2023]
Abstract
Purpose Sodium-glucose cotransporter-2 (SGLT2) inhibitor empagliflozin has recently been shown to improve the outcomes of heart failure (HF) patients regardless of patient's left ventricular ejection fraction by reducing the combined risk of cardiovascular death or hospitalization for worsening HF. The aim of this study was to assess the cost-effectiveness of adding empagliflozin to the standard care (SC) in comparison to SC only in the treatment of HF in Finland. Patients and Methods The assessment was performed in the cost-utility framework using two Markov cohort state-transition models, one for HF with reduced ejection fraction (HFrEF) and one for HF with preserved ejection fraction (HFpEF). The models have been primarily developed based on the EMPEROR-Reduced and EMPEROR-Preserved trials which informed the modelled patient characteristics, efficacy of treatments in terms of associated risks for heart failure hospitalizations, cardiovascular (CV) and non-CV death, treatment related adverse events (AE), and state- and event-specific health-related quality of life weights (EQ-5D). Direct health care costs were estimated from Finnish published references. Cost-effectiveness was assessed from health care payer perspective based on incremental cost-effectiveness ratio (ICER; cost per quality adjusted life-year [QALY] gained) and probability of cost-effectiveness (at willingness-to-pay [WTP] of 35,000 euros/QALY). The ICER was reported as the weighted (HFrEF, 43.5%; HFpEF, 56.5%) average result of the two models. Results Empagliflozin + SC treatment increased the average quality-adjusted life-expectancy, and treatment costs of HF patients by 0.15 QALYs and 1,594 euros, respectively, when compared to SC. An additional QALY with empagliflozin was thus gained at a cost of 10,621 euros. The probability of empagliflozin + SC being cost-effective compared to placebo + SC was 77.6% and 83.5% with WTP of 35,000 and 100,000 euros/QALY, respectively. Conclusion Empagliflozin is a cost-effective treatment for patients with HF in the Finnish health care setting.
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Affiliation(s)
- Taru Hallinen
- ESiOR Oy, Kuopio, Finland,Correspondence: Taru Hallinen, ESiOR Oy, Tulliportinkatu 2 LT 4, Kuopio, FI-70100, Finland, Tel +358 50 568 1894, Email
| | | | | | - Veli-Pekka Harjola
- Emergency Medicine, University of Helsinki, Department of Emergency Medicine and Services, Helsinki University Hospital, Helsinki, Finland
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Goudarzi Z, Ghafari Darab M, Vazin A, Hayatbakhsh A, Karimzadeh I, Jafari M, Keshavarz K, Borhani-Haghighi A. Oral Anticoagulants for Stroke Prevention in Atrial Fibrillation: A Systematic Review of Economic Evaluations. Value Health Reg Issues 2023; 33:99-108. [PMID: 36402007 DOI: 10.1016/j.vhri.2022.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 08/19/2022] [Accepted: 09/30/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Several studies have evaluated the economic evaluation of a group of medications known as novel oral anticoagulant drugs (NOACs) in recent years. The aim of this study is to review and systematically analyze the cost-utility studies results of warfarin compared with other NOAC drugs in atrial fibrillation patients. METHODS A systematic review was performed to identify all studies evaluating the NOAC medications in comparison with warfarin. For this purpose, PubMed, Cochrane Library, ISI Web of Science, and Scopus were searched from 2013 to 2022. Articles were independently screened with inclusion criteria, and full texts were reviewed. First, the Consolidated Health Economic Evaluation Reporting Standards checklist was used to evaluate the quality of the articles. Then, the costs and outcomes of the studies were analyzed, and findings were appraised critically. RESULTS A total of 84 costs-per-quality-adjusted life-year (QALY) cases were extracted from the studies in which the share of rivaroxaban, edoxaban, apixaban, and dabigatran were 31%, 13%, 29%, and 27%, respectively. The median cost per QALY of rivaroxaban, edoxaban, apixaban, and dabigatran was 21 910$/QALY, 22 096$/QALY, 17 765$/QALY, and 24 161$/QALY, respectively. Subgroup analysis based on perspective showed that dabigatran had the highest incremental cost-effectiveness ratio (ICER) and edoxaban had the lowest ICER value. Edoxaban and apixaban had the highest and the lowest cost per QALY from an insurance perspective, respectively. CONCLUSION Despite the differences and variations in the economic evaluation studies of NOAC drugs, these drugs have shown acceptable cost-effectiveness in developed and developing countries. Among NOAC drugs, apixaban has the lowest ICER and the highest cost-effectiveness.
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Affiliation(s)
- Zahra Goudarzi
- Health Human Resources Research Centre, School of Health Management and Information Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohsen Ghafari Darab
- Deakin University, Geelong, VIC, Australia; Institute for Medical Management and Health Sciences, University of Bayreuth, Bayreuth, Germany
| | - Afsaneh Vazin
- Department of Clinical Pharmacy, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Amirreza Hayatbakhsh
- Department of Clinical Pharmacy, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Iman Karimzadeh
- Department of Clinical Pharmacy, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mojtaba Jafari
- Health Human Resources Research Centre, School of Health Management and Information Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Khosro Keshavarz
- Health Human Resources Research Centre, School of Health Management and Information Sciences, Shiraz University of Medical Sciences, Shiraz, Iran; Emergency Medicine Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
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Volgman AS, Nair G, Lyubarova R, Merchant FM, Mason P, Curtis AB, Wenger NK, Aggarwal NT, Kirkpatrick JN, Benjamin EJ. Management of Atrial Fibrillation in Patients 75 Years and Older: JACC State-of-the-Art Review. J Am Coll Cardiol 2022; 79:166-179. [PMID: 35027110 DOI: 10.1016/j.jacc.2021.10.037] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 10/18/2021] [Indexed: 12/11/2022]
Abstract
The prevalence of atrial fibrillation (AF) is increasing as the population ages. AF treatment-related complications also increase markedly in older adults (defined as ≥75 years of age for this review). The older AF population has a high risk of stroke, bleeding, and death. Syncope and fall-related injuries are the most common reasons for nonprescription of oral anticoagulation (OAC), and are more common in older adults when OACs are used with antiarrhythmic drugs. Digoxin may be useful for rate control, but associations with increased mortality limit its use. Beyond rate and rhythm control considerations, stroke prophylaxis is critical to AF management, and the benefits of direct OACs, compared with warfarin, extend to older adults. Invasive procedures such as AF catheter ablation, pacemaker implantation/atrioventricular junction ablation, and left atrial appendage occlusion may be useful in appropriately selected cases. However, older adults have generally been under-represented in clinical trials.
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Affiliation(s)
| | - Gatha Nair
- Division of Cardiology, Rush University Medical Center, Chicago, Illinois, USA
| | - Radmila Lyubarova
- Division of Cardiology, Albany Medical Center, Albany, New York, USA
| | - Faisal M Merchant
- Department of Medicine, Section of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Pamela Mason
- Department of Cardiology, University of Virginia, Charlottesville, Virginia, USA
| | - Anne B Curtis
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Nanette K Wenger
- Department of Medicine, Section of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Neelum T Aggarwal
- Departments of Neurological Sciences, Rush Alzheimer's Disease Center, Rush University Medical Center, Chicago, Illinois, USA
| | | | - Emelia J Benjamin
- Boston Medical Center, and Boston University School of Medicine and School of Public Health, Boston, Massachusetts, USA
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