Department of Medical Services, Ministry of Public Health, Nonthaburi 11000, Thailand.
Population Health Sciences, Bristol Medical School, University of Bristol, Bristol BS8 2BN, UK.
Int J Environ Res Public Health. 2023 Feb 11;20(4):3176. doi: 10.3390/ijerph20043176.
Direct oral anticoagulants (DOACs) have been used for venous thromboembolism (VTE) in Thailand. However, they have not been listed in the National List of Essential Medicines (NLEM). A cost-effectiveness analysis is needed to aid policymakers in deciding whether DOACs should be listed in the NLEM. This study aimed to assess the cost-effectiveness of DOACs for patients with VTE in Thailand.
A cohort-based state transition model was constructed from a societal perspective with a lifetime horizon. All available DOACs, including apixaban, rivaroxaban, edoxaban, and dabigatran, were compared with warfarin. A 6-month cycle length was used to capture all costs and health outcomes. The model consisted of nine health states, including VTE on treatment, VTE off treatment, recurrent VTE, clinically relevant non-major bleeding, gastrointestinal bleeding, intracranial bleeding, post-intracranial bleeding, chronic thromboembolic pulmonary hypertension, and death. All inputs were based on a comprehensive literature review. The model outcomes included total cost and quality-adjusted life-years (QALYs) with a 3% annual discount rate. A fully incremental cost-effectiveness analysis and the incremental cost-effectiveness ratio (ICER) per QALY gained were calculated at a willingness-to-pay (WTP) of THB 160,000/QALY ($5003). The robustness of the findings was assessed using deterministic and probabilistic sensitivity analyses.
All DOACs were associated with a decreased risk of VTE recurrence and intracranial hemorrhage. In the base-case analysis, apixaban could increase 0.16 QALYs compared with warfarin. An ICER for apixaban was 269,809 Thai baht (THB)/QALY ($8437/QALY). Rivaroxaban had a better QALY than warfarin at 0.09 QALYs with an ICER of 757,363 THB/QALY ($23,682/QALY). Edoxaban and dabigatran could also increase by 0.10 QALYs with an ICER of 709,945 THB ($22,200) and 707,145 THB ($22,122)/QALY, respectively. Our probabilistic sensitivity analyses indicated that warfarin had a 99.8% possibility of being cost-effective, while apixaban had a 0.2% possibility of being cost-effective at the current WTP. Other DOACs had no possibility of being cost-effective.
All DOACs were not cost-effective for VTE treatment at the current WTP in Thailand. Apixaban is likely to be the best option among DOACs.
直接口服抗凝剂（DOAC）已在泰国用于治疗静脉血栓栓塞症（VTE）。然而，它们并未被列入国家基本药物目录（NLEM）。需要进行成本效益分析，以帮助决策者决定 DOAC 是否应列入 NLEM。本研究旨在评估 DOAC 在泰国治疗 VTE 患者的成本效益。
从社会角度构建了基于队列的状态转换模型，具有终生时间范围。比较了所有可用的 DOAC，包括阿哌沙班、利伐沙班、依度沙班和达比加群，与华法林相比。采用 6 个月的周期长度来捕获所有成本和健康结果。模型由九个健康状态组成，包括治疗中的 VTE、治疗结束后的 VTE、复发性 VTE、临床相关非大出血、胃肠道出血、颅内出血、颅内出血后、慢性血栓栓塞性肺动脉高压和死亡。所有投入均基于全面的文献回顾。模型结果包括总费用和质量调整生命年（QALYs），贴现率为 3%。以 THB 160,000/QALY（$5003）的支付意愿（WTP）计算了完全增量成本效益分析和每获得一个 QALY 的增量成本效益比（ICER）。使用确定性和概率敏感性分析评估了研究结果的稳健性。
所有 DOAC 均与降低 VTE 复发和颅内出血风险相关。在基础案例分析中，与华法林相比，阿哌沙班可增加 0.16 个 QALY。阿哌沙班的 ICER 为 269,809 泰铢（THB）/QALY（$8437/QALY）。与华法林相比，利伐沙班的 QALY 增加了 0.09，ICER 为 757,363 泰铢/QALY（$23,682/QALY）。依度沙班和达比加群也可以增加 0.10 QALY，ICER 分别为 709,945 泰铢（$22,200）和 707,145 泰铢（$22,122）/QALY。我们的概率敏感性分析表明，在当前的 WTP 下，华法林有 99.8%的可能性具有成本效益，而阿哌沙班有 0.2%的可能性具有成本效益。其他 DOAC 没有可能具有成本效益。
在泰国目前的 WTP 下，所有 DOAC 均不具有治疗 VTE 的成本效益。阿哌沙班可能是 DOAC 中的最佳选择。
