OBJECTIVES

Evidence on cost-effectiveness of direct oral anticoagulants (DOACs) versus warfarin among atrial fibrillation (AF) patients with varying stroke and bleeding risks is not straightforward because stroke and bleeding share common risk factors. The present study aimed to examine the cost-effectiveness of apixaban, dabigatran, rivaroxaban, and edoxaban compared to warfarin in AF patients with different risk profiles.

METHODS

A Markov micro-simulation (12 states) was adapted to examine the lifetime costs and quality-adjusted survival (QALYs) of five anticoagulants according to U.S. private payer’s perspective. The hypothetical cohort consisted of 10,000 AF patients with age, CHADS2-VASc and HAS-BLED scores similar to a commercially insured AF patient cohort (IBM MarketScan®). Patients were grouped into 9 subgroups based on their CHADS2-VASc and HAS-BLED scores. Transition probabilities estimated from IBM MarketScan® and literature were dependent upon anticoagulant treatments and the subgroup patients were in. Costs and utilities were obtained from the literature. Deterministic and probabilistic sensitivity analyses were conducted. Subgroup analysis for each stroke and bleed risk subgroup and age were also performed.

RESULTS

All DOACs had incremental cost-effectiveness ratio (ICER) <$100,000/QALY relative to the common comparator warfarin, the optimal treatment strategy was dabigatran (ICER=$35,055/QALY). After eliminating rivaroxaban and apixaban (dominated strategies), ICER was $36,577/QALY for edoxaban relative to warfarin and $30,826/QALY for dabigatran relative to edoxaban. Subgroup analysis indicated edoxaban were cost-effective compare to dabigatran among patients with low bleed risk.

CONCLUSIONS

This study provided evidence on the cost-effectiveness of five anticoagulants for patients with atrial fibrillation which can inform clinical decision making about treatment selection. The results suggested dabigatran was cost-effective compared to other treatment options among general AF population, while edoxaban was cost-effective compared to other treatments among patients with low bleed risk.