Department of Geographical and Historical Studies, University of Eastern Finland, P.O. Box 111, 80101, Joensuu, Finland.
Faculty of Medicine and Health Technology, Tampere University, Kalevantie 4, 33100, Tampere, Finland.
BMC Health Serv Res. 2019 Nov 27;19(1):901. doi: 10.1186/s12913-019-4711-z.
Anticoagulation therapy is used for atrial fibrillation (AF) patients for reducing the risk of cardioembolic complications such as stroke. The previously recommended anticoagulant, warfarin, has a narrow therapeutic window, and it requires regular laboratory monitoring, unlike direct oral anticoagulants (DOAC). From a societal perspective, it is important to measure time and travel costs associated with warfarin monitoring to better compare the total therapy costs of these two alternative forms of anticoagulation management. In this study we design a georeferenced cost model to investigate societal savings achievable with the shift from warfarin to DOACs in the study region of North Karelia in Eastern Finland.
Individual-level patient data of 6519 AF patients was obtained from the regional patient database. Patients' geocoded home addresses and other GIS data were used to perform a network analysis for the optimal routes for warfarin monitoring visits. These measures of revealed accessibility were then used in the cost model to measure monetary time and travel costs in addition to direct healthcare costs of anticoagulation management.
The share of time and travel costs in warfarin monitoring is 26.6% of the total therapy costs in our study region. With current drug retail prices in Finland, the societal expense of anticoagulation management is only 2.6% higher with DOACs than in the baseline with warfarin. However, when 25% lower distributor's prices are used, the total societal cost decreases by 13.6% with DOACs.
Our results indicate that patients' time and travel costs critically increase the societal cost of warfarin therapy; and despite the higher price of DOACs, they are already cost-efficient alternatives to warfarin in anticoagulation management. In the future, the cost of AF complications should be included in the cost comparison between warfarin and DOACs. Our modeling approach applies to different geographical regions and to different healthcare processes requiring patient monitoring.
抗凝治疗用于房颤（AF）患者，以降低心源性栓塞并发症（如中风）的风险。以前推荐的抗凝药物华法林，治疗窗较窄，需要定期进行实验室监测，这与直接口服抗凝剂（DOAC）不同。从社会角度来看，衡量与华法林监测相关的时间和旅行成本很重要，以便更好地比较这两种替代抗凝管理方式的总治疗成本。在这项研究中，我们设计了一个地理参考成本模型，以调查从华法林转向 DOAC 在芬兰东部北卡累利阿研究区域可实现的社会节约。
从区域患者数据库中获取了 6519 名 AF 患者的个体水平患者数据。患者的地理编码家庭住址和其他 GIS 数据用于进行网络分析，以确定华法林监测访问的最佳路线。这些可揭示的可达性度量被用于成本模型，以衡量除抗凝管理的直接医疗成本之外的货币时间和旅行成本。
在我们的研究区域，时间和旅行成本占华法林监测总成本的 26.6%。在芬兰，以目前的药品零售价格计算，与华法林相比，DOAC 的社会抗凝管理费用仅高出 2.6%。然而，当使用 25%的更低分销商价格时，DOAC 的总社会成本下降了 13.6%。
我们的研究结果表明，患者的时间和旅行成本极大地增加了华法林治疗的社会成本；尽管 DOAC 的价格较高，但它们已经是抗凝管理中比华法林更具成本效益的替代方案。未来，应将 AF 并发症的成本纳入华法林和 DOAC 之间的成本比较。我们的建模方法适用于不同的地理区域和需要患者监测的不同医疗保健流程。
