OBJECTIVES : Economic consequences associated with the rise in non-vitamin K antagonist (VKA) oral anticoagulant use on a societal level remain unclear. A systematic literature review (SLR) was conducted to summarize evidence on economic burden in atrial fibrillation (AF), with a focus on indirect costs related to stroke, bleeding, and VKA monitoring.

METHODS : Searches were executed—according to best practices—in MEDLINE and Embase to identify observational studies and economic evaluations published from January 1, 2008 to March 9, 2018 that reported economic data on stroke, bleeding, and/or monitoring in AF patients.

RESULTS : The SLR identified 158 studies—118 on resource use, 99 on direct costs, and 13 on indirect costs (8 observational and 5 economic evaluations). The types of indirect costs reported were heterogeneous, including productivity losses (n=8), caregiver costs (n=4) and the opportunity cost of lost time (n=4). Only 1 study reported indirect costs associated with bleeding, as compared to 7 for VKA monitoring and 5 for stroke. Indirect stroke or major bleeding costs contributed marginally to total costs (1.1%–2.6%) when evaluated over a short follow-up. However, 2 observational studies with 3-year data showed that the contribution of productivity losses increased substantially after the incident year (1.2%–1.4% in the incident year, 28%–48% 2 years post-event). A more pronounced contribution of indirect costs of stroke to total costs was identified in economic evaluations, likely due to consideration of a longer-term horizon. Indirect costs of VKA monitoring comprised 1%–52% of total costs when productivity losses were considered and 13%–78% when cost of lost time of caregivers and patients was considered.

CONCLUSIONS : When a holistic approach is adopted, the contribution of indirect costs to total costs appears to be far from trivial. Given the paucity in evidence identified, further evaluation of indirect costs associated with AF management and complications is needed.