OBJECTIVES: To stablish within-study and between study variations in incremental cost-utility ratios (ICUR) of direct oral anticoagulants (DOAC) versus vitamin K antagonists (VKA) for atrial fibrillation (AF) patients across EU-5 countries. Additionally, we aimed to perform a descriptive comparison between total sales per country and ICURs identified.

METHODS: OVID-Medline and Embase were systematically searched for original publications of cost-utility analyses reporting ICURs for any DOAC versus VKA in AF in France, Germany, Italy, Spain or United Kingdom (UK) published between 2010 and 2017. Minimum and maximum ICURs and one-way sensitivity analyses (OWSA) results were collected. ICURs reported for UK were transformed into Euros (€). DOACs sales from April 2016 to March 2017 were extracted for each country from QuintilesIMS MIDAS database. Sold units per AF patient were calculated based on reported prevalence per country and overall population in 2016.

RESULTS: A total of 624 unique references were identified, 16 publications reporting 26 cost-utility analyses for France (2), Germany (7), Italy (5), Spain (5) and the UK (7) were included. Minimum and maximum ICUR per country were 12.227€ and 15.838€ for France, 15.207€ and 294.349€ for Germany, 6.800€ and 16.162€ for Italy, 6.397€ and 29.957€ for Spain and 5.637€ and 25.886€ for UK. The variable with the highest impact on ICURs in OWSA was risk of ictus associated to DOAC, followed by drug acquisition cost and time horizon. Italy was the country with the highest DOAC units sold per AF patient followed by Germany, UK, France and Spain.

CONCLUSIONS: Differences between DOAC’s ICURs and sales per AF patient arose across countries. Italy was the country for which a lowest DOAC vs VKA ICUR was reported and it was also associated with the highest DOAC units sold per AF patient. However, there seems to be additional criteria other than ICUR driving DOAC’s use.