Groupe d'analyse , Ltée, Montréal, Québec , Canada.
J Med Econ. 2014 Jan;17(1):52-64. doi: 10.3111/13696998.2013.858634. Epub 2013 Nov 14.
Venous thromboembolism (VTE), comprised of deep vein thrombosis (DVT) and pulmonary embolism (PE), is commonly treated with a low-molecular-weight heparin such as enoxaparin plus a vitamin K antagonist (VKA) to prevent recurrence. Administration of enoxaparin + VKA is hampered by complexities of laboratory monitoring and frequent dose adjustments. Rivaroxaban, an orally administered anticoagulant, has been compared with enoxaparin + VKA in the EINSTEIN trials. The objective was to evaluate the cost-effectiveness of rivaroxaban compared with enoxaparin + VKA as anticoagulation treatment for acute, symptomatic, objectively-confirmed DVT or PE.
A Markov model was built to evaluate the costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios associated with rivaroxaban compared to enoxaparin + VKA in adult patients treated for acute DVT or PE. All patients entered the model in the 'on-treatment' state upon commencement of oral rivaroxaban or enoxaparin + VKA for 3, 6, or 12 months. Transition probabilities were obtained from the EINSTEIN trials during treatment and published literature after treatment. A 3-month cycle length, US payer perspective ($2012), 5-year time horizon and a 3% annual discount rate were used.
Treatment with rivaroxaban cost $2,448 per-patient less and was associated with 0.0058 more QALYs compared with enoxaparin + VKA, making it a dominant economic strategy. Upon one-way sensitivity analysis, the model's results were sensitive to the reduction in index VTE hospitalization length-of-stay associated with rivaroxaban compared with enoxaparin + VKA. At a willingness-to-pay threshold of $50,000/QALY, probabilistic sensitivity analysis showed rivaroxaban to be cost-effective compared with enoxaparin + VKA approximately 76% of the time.
The model did not account for the benefits associated with an oral and minimally invasive administration of rivaroxaban. 'Real-world' applicability is limited because data from the EINSTEIN trials were used in the model. Also, resource utilization and costs were based on the US healthcare system.
Rivaroxaban is a cost-effective option for anticoagulation treatment of acute VTE patients.
静脉血栓栓塞症（VTE）包括深静脉血栓形成（DVT）和肺栓塞（PE），通常采用低分子肝素如依诺肝素加维生素 K 拮抗剂（VKA）治疗，以预防复发。依诺肝素+VKA 的应用受到实验室监测和频繁剂量调整的复杂性的限制。利伐沙班是一种口服抗凝剂，已在 EINSTEIN 试验中与依诺肝素+VKA 进行了比较。目的是评估利伐沙班与依诺肝素+VKA 作为急性、有症状、客观证实的 DVT 或 PE 的抗凝治疗相比的成本效益。
建立了一个马尔可夫模型，以评估利伐沙班与依诺肝素+VKA 相比，在治疗急性 DVT 或 PE 的成年患者中的成本、质量调整生命年（QALYs）和增量成本效益比。所有患者在开始口服利伐沙班或依诺肝素+VKA 治疗 3、6 或 12 个月后进入模型的“治疗中”状态。治疗期间从 EINSTEIN 试验中获得转移概率，并在治疗后从已发表的文献中获得。使用 3 个月的周期长度、美国支付者视角（$2012）、5 年时间范围和 3%的年度贴现率。
与依诺肝素+VKA 相比，利伐沙班的治疗费用每位患者减少$2448，且 QALYs 增加 0.0058，使其成为一种具有优势的经济策略。在单向敏感性分析中，模型的结果对利伐沙班与依诺肝素+VKA 相比减少的指数 VTE 住院时间长度敏感。在支付意愿阈值为$50000/QALY 的情况下，概率敏感性分析显示利伐沙班与依诺肝素+VKA 相比约有 76%的时间是具有成本效益的。
该模型没有考虑到与利伐沙班的口服和微创给药相关的益处。由于模型中使用了 EINSTEIN 试验的数据，因此“实际”适用性有限。此外，资源利用和成本是基于美国医疗保健系统的。
利伐沙班是急性 VTE 患者抗凝治疗的一种具有成本效益的选择。
