From the Ivey Business School, University of Western Ontario, London, Canada (E.R.V., S.A.W.L., L.E.C.).
Department of Clinical Neurological Sciences, London Health Sciences Centre (L.A.S., V.H.), Western University, London, ON, Canada.
Stroke. 2018 Dec;49(12):2844-2850. doi: 10.1161/STROKEAHA.118.022596.
Background and Purpose- Direct oral anticoagulants (DOACs) are safer, at least equally efficacious, and cost-effective compared to warfarin for stroke prevention in atrial fibrillation (AF) but they remain underused, particularly in demented patients. We estimated the cost-effectiveness of DOACs compared with warfarin in patients with AF and Alzheimer's disease (AD). Methods- We constructed a microsimulation model to estimate the lifetime costs, quality-adjusted life-years (QALYs), and cost-effectiveness of anticoagulation therapy (adjusted-dose warfarin and various DOACs) in 70-year-old patients with AF and AD from a US societal perspective. We stratified patient cohorts based on stage of AD and care setting. Model parameters were estimated from secondary sources. Health benefits were measured in the number of acute health events, life-years, and QALYs gained. We classified alternatives as cost-effective using a willingness-to-pay threshold of $100 000 per QALY gained. Results- For patients with AF and AD, compared with warfarin, DOACs increase costs but also increase QALYs by reducing the risk of stroke. For mild-AD patients living in the community, edoxaban increased lifetime costs by $6603 and increased QALYs by 0.076 compared to warfarin, yielding an incremental cost-effectiveness ratio of $86 882/QALY gained. Even though DOACs increased QALYs compared with warfarin for all patient groups (ranging from 0.019 to 0.085 additional QALYs), no DOAC treatment alternative had an incremental cost-effectiveness ratio <$150 000/QALY gained for patients with moderate to severe AD. For patients living in a long-term care facility with mild AD, the DOAC with the lowest incremental cost-effectiveness ratio (rivaroxaban) costs $150 169 per QALY gained; for patients with more severe AD, the incremental cost-effectiveness ratios were higher. Conclusions- For patients with AF and mild AD living in the community, edoxaban is cost-effective compared with warfarin. Even though patients with moderate and severe AD living in the community and patients with any stage of AD living in a long-term care setting may obtain positive clinical benefits from anticoagulation treatment, DOACs are not cost-effective compared with warfarin for these populations. Compared to aspirin, no oral anticoagulation (warfarin or any DOAC) is cost effective in patients with AF and AD.
背景与目的-与华法林相比，直接口服抗凝剂（DOACs）在预防房颤（AF）中的卒中风险方面更安全，至少同样有效，并且具有成本效益，但它们的使用率仍然较低，尤其是在痴呆患者中。我们评估了 DOACs 与华法林在 AF 合并阿尔茨海默病（AD）患者中的成本效益。方法-我们构建了一个微观模拟模型，从美国社会角度估计 70 岁 AF 合并 AD 患者抗凝治疗（调整剂量华法林和各种 DOACs）的终生成本、质量调整生命年（QALYs）和成本效益。我们根据 AD 阶段和护理环境对患者队列进行分层。模型参数是从二次来源估计的。健康益处是通过急性健康事件数量、生命年和获得的 QALY 来衡量的。我们使用获得的每 QALY 愿意支付 100000 美元的意愿支付阈值来分类替代方案是否具有成本效益。结果-对于 AF 合并 AD 患者，与华法林相比，DOACs 通过降低卒中风险增加了成本，但也增加了 QALYs。对于居住在社区的轻度 AD 患者，与华法林相比，依度沙班增加了终生成本 6603 美元，并增加了 0.076 个 QALY，增量成本效益比为 86882 美元/QALY。尽管对于所有患者组（范围从 0.019 到 0.085 个额外的 QALY），与华法林相比，DOACs 都增加了 QALYs，但对于中度至重度 AD 患者，没有任何 DOAC 治疗选择的增量成本效益比低于 150000 美元/QALY。对于居住在轻度 AD 长期护理机构的患者，具有最低增量成本效益比的 DOAC（利伐沙班）每 QALY 成本为 150169 美元；对于更严重的 AD 患者，增量成本效益比更高。结论-对于居住在社区的轻度 AD 患者，与华法林相比，依度沙班具有成本效益。即使对于居住在社区的中度和重度 AD 患者以及居住在长期护理机构的任何阶段 AD 患者，抗凝治疗可能会带来积极的临床获益，但与华法林相比，DOACs 对这些人群并不具有成本效益。与阿司匹林相比，在 AF 合并 AD 患者中，没有任何口服抗凝剂（华法林或任何 DOAC）具有成本效益。
Zotero 插件