Abstract
The objective of this analysis was to compare costs and effectiveness of different Novel Oral Anticoagulants (NOACs) in the primary prevention of stroke and systemic embolism in patients with atrial fibrillation. Currently NOACs are reimbursed after warfarin as a secondary prevention only. To assess on cost-utility of apixaban, a Markov model was developed. The analysis was focused on the first line prevention of stroke and systemic embolism in vitamin K antagonist (VKA) suitable patients suffering from atrial fibrillation with at least one risk factor present (symptomatic heart failure of class II or higher according to NYHA classification, age of 75 years or higher, diabetes mellitus, hypertension). Apixaban, dabigatran, edoxaban and rivaroxaban were compared in terms of lifetime costs per quality-adjusted life year based on recent network-meta analysis of NOACs. Drug costs, acute care costs, and management costs were assumed. The analysis was conducted from the perspective of the public healthcare payer in the Czech Republic over a lifetime horizon. Numerically, apixaban appears to be the most suitable treatment. Incremental Cost-effectiveness Ratio (ICER) for apixaban vs. dabigatran reached 11 186 EUR/QALY with 0,063 QALY and 0,078 LYG gained; apixaban vs. rivaroxaban 3 674 EUR/QALY with 0,059 QALY and 0,075 LYG gained and finally apixaban vs. edoxaban 60 mg 5 429 EUR/QALY with 0,072 QALY and 0,083 LYG gained. Methodologic, probabilistic and sensitivity analyses confirmed the added value of apixaban treatment. Based on the numerical results apixaban is the best alternative among NOACs prolonging total survival and improving quality of life of VKA suitable patients with atrial fibrillation. Use of apixaban brought lower risk of serious events. Results indicate apixaban treatment is also the most cost-effective alternative with ICER well below Czech willingness to pay threshold 44 894 EUR/QALY.
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