Cost-effectiveness analysis of apixaban versus vitamin K antagonists for antithrombotic therapy in patients with atrial fibrillation after acute coronary syndrome or percutaneous coronary intervention in Spain.

Simone Rivolo,Javier Soto,Carlos Polanco,Amiee Kang,Aristeidis Skandamis,Manuela Di Fusco,Mirko Savone,Thitima Kongnakorn,Devender Dhanda,Nienke Van Rein

doi:10.1371/journal.pone.0259251

Abstract

Background/ObjectiveAUGUSTUS trial demonstrated that, for patients with atrial fibrillation (AF) having acute coronary syndrome (ACS) or undergoing percutaneous coronary intervention (PCI), an antithrombotic regimen with apixaban and P2Y12 resulted in less bleeding, fewer hospitalizations, and similar ischemic events than regimens including a vitamin K antagonist (VKA), aspirin, or both. This study objective was to evaluate long-term health and economic outcomes and the cost-effectiveness of apixaban over VKA, as a treatment option for patients with AF having ACS/PCI.MethodsA lifetime Markov cohort model was developed comparing apixaban versus VKA across multiple treatment strategies (triple [with P2Y12 + aspirin] or dual [with P2Y12] therapy followed by monotherapy [apixaban or VKA]; triple followed by dual and then monotherapy; dual followed by monotherapy). The model adopted the Spanish healthcare perspective, with a 3-month cycle length and costs and health outcomes discounted at 3%.ResultsTreatment with apixaban resulted in total cost savings of €883 and higher life years (LYs) and quality-adjusted LYs (QALYs) per patient than VKA (net difference, LYs: 0.13; QALYs: 0.11). Bleeding and ischemic events (per 100 patients) were lower with apixaban than VKA (net difference, –13.9 and –1.8, respectively). Incremental net monetary benefit for apixaban was €3,041, using a willingness-to-pay threshold of €20,000 per QALY. In probabilistic sensitivity analysis, apixaban was dominant in the majority of simulations (92.6%), providing additional QALYs at lower costs than VKA.ConclusionsApixaban was a dominant treatment strategy than VKA from both the Spanish payer’s and societal perspectives, regardless of treatment strategy considered.

Highlights

Atrial fibrillation (AF) is the most common form of cardiac dysrhythmia associated with substantial morbidity and mortality with increasing age [1, 2]
A lifetime Markov cohort model was developed comparing apixaban versus vitamin K antagonist (VKA) across multiple treatment strategies
Treatment with apixaban resulted in total cost savings of €883 and higher life years (LYs) and quality-adjusted LYs (QALYs) per patient than VKA

Summary

Introduction

Atrial fibrillation (AF) is the most common form of cardiac dysrhythmia associated with substantial morbidity and mortality with increasing age [1, 2]. Patients with AF having ACS or undergoing percutaneous coronary intervention (PCI) are more likely to experience complications [6,7,8] and mortality [9, 10], incurring substantial total healthcare costs [11]. Clinical management of AF and ACS, different, includes antithrombotic therapy to prevent increased risk of stroke and further cardiac events [1, 4, 12]. The optimal antithrombotic regimen for patients with AF having ACS/PCI remains a clinical conundrum due to an increased risk of major and fatal bleedings associated with a combination of OAC and DAPT (i.e., triple therapy) [1, 4, 12, 13]. There is limited guidance on the optimal strategy and lack of evidence for all possible combinations of novel antiplatelet and anticoagulant agents

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Results

Conclusion