Poulsen Peter Bo, Johnsen Søren Paaske, Hansen Morten Lock, Brandes Axel, Husted Steen, Harboe Louise, Dybro Lars
Pfizer Denmark ApS, Ballerup.
Department of Clinical Epidemiology, Aarhus University Hospital.
Clinicoecon Outcomes Res. 2017 Oct 13;9:617-627. doi: 10.2147/CEOR.S145813. eCollection 2017.
Resources devoted to health care are limited, therefore setting priorities is required. It differs between countries whether decision-making concerning health care technologies focus on broad economic perspectives or whether focus is narrow on single budgets ("silo mentality"). The cost perspective as one part of the full health economic analysis is important for decision-making. With the case of oral anticoagulants in patients with nonvalvular atrial fibrillation (NVAF), the aim is to discuss the implication of the use of different cost perspectives for decision-making and priority setting.
In a cost analysis, the annual average total costs of five oral anticoagulants (warfarin and non-vitamin K oral anticoagulants [NOACs; dabigatran, rivaroxaban, apixaban, and edoxaban]) used in daily clinical practice in Denmark for the prevention of stroke in NVAF patients are analyzed. This is done in pairwise comparisons between warfarin and each NOAC based on five potential cost perspectives, from a "drug cost only" perspective up to a "societal" perspective.
All comparisons of warfarin and NOACs show that the cost perspective based on all relevant costs, ie, total costs perspective, is essential for the choice of therapy. Focusing on the reimbursement costs of the drugs only, warfarin is the least costly option. However, with the aim of therapy to prevent strokes and limit bleedings, including the economic impact of this, all NOACs, except rivaroxaban, result in slightly lower health care costs compared with warfarin. The same picture was found applying the societal perspective.
Many broad cost-effectiveness analyses of NOACs exist. However, in countries with budget focus in decision-making this information does not apply. The present study's case of oral anticoagulants has shown that decision-making should be based on health care or societal cost perspectives for optimal use of limited resources. Otherwise, the risk is that suboptimal decisions will be likely.
用于医疗保健的资源有限，因此需要确定优先事项。在医疗技术的决策方面，各国存在差异，有的侧重于广泛的经济视角，有的则局限于单一预算（“竖井思维”）。成本视角作为全面卫生经济分析的一部分，对决策很重要。以非瓣膜性心房颤动（NVAF）患者使用口服抗凝剂为例，旨在探讨使用不同成本视角对决策和确定优先事项的影响。
在一项成本分析中，对丹麦日常临床实践中用于预防NVAF患者中风的五种口服抗凝剂（华法林和非维生素K口服抗凝剂[NOACs；达比加群、利伐沙班、阿哌沙班和依度沙班]）的年平均总成本进行了分析。这是基于从“仅药物成本”视角到“社会”视角的五个潜在成本视角，对华法林与每种NOAC进行两两比较得出的。
华法林与NOACs的所有比较均表明，基于所有相关成本的成本视角，即总成本视角，对治疗选择至关重要。仅关注药物的报销成本，华法林是成本最低的选择。然而，以预防中风和减少出血为治疗目标，包括其经济影响，除利伐沙班外，所有NOACs与华法林相比，医疗保健成本略低。从社会视角来看也是如此。
存在许多关于NOACs的广泛成本效益分析。然而，在决策以预算为重点的国家，这些信息并不适用。本研究中口服抗凝剂的案例表明，决策应基于医疗保健或社会成本视角，以优化有限资源的利用。否则，可能会做出次优决策。
