OBJECTIVES

Atrial fibrillation (AF) is the most common cardiac arrhythmia that increases stroke risk and leads to higher medical spending. Using a US payer perspective, we evaluated the cost-effectiveness of dabigatran versus rivaroxaban for stroke prevention in patients with AF. We improved on existing cost effectiveness analyses (CEAs) by incorporating the impact of medication persistence on clinical and economic outcomes.

METHODS

A Markov model with an annual cycle and lifetime horizon was constructed to simulate the disease progression in a hypothetical cohort of 65 years old patients with AF treated with dabigatran or rivaroxaban. All patients started in the healthy state and progressed to have a stroke and eventually die. Healthcare costs associated with each health state and the transition probabilities between the health states depended on medication persistence. The incremental cost-effectiveness ratio (ICER) was reported to compare treatments. Model robustness was checked with univariate and probabilistic sensitivity analyses (PSA).

RESULTS

In the base case, rivaroxaban provided 6.72 quality-adjusted life years (QALYs) at the cost of $148,907, while dabigatran provided 6.66 QALYs at the cost of $103,066. Compared to dabigatran, rivaroxaban provided an additional 0.07 QALYs at the additional cost of $45,840, resulting in the ICER of $672,005 per QALY. However, the base case results were not robust in PSA. In deterministic sensitivity analysis, the most influential parameters were health state utility and the costs of dabigatran and rivaroxaban

CONCLUSIONS

The small difference in the incremental QALY was not robust in our sensitivity analysis. Therefore, there is no clear evidence that either treatment has better relative value.