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      Cost-Effectiveness of Rivaroxaban Versus Warfarin for Stroke Prevention in Atrial Fibrillation in the Belgian Healthcare Setting

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          Abstract

          Background

          Warfarin, an inexpensive drug that has been available for over half a century, has been the mainstay of anticoagulant therapy for stroke prevention in patients with atrial fibrillation (AF). Recently, rivaroxaban, a novel oral anticoagulant (NOAC) which offers some distinct advantages over warfarin, the standard of care in a world without NOACs, has been introduced and is now recommended by international guidelines.

          Objective

          The aim of this study was to evaluate, from a Belgian healthcare payer perspective, the cost-effectiveness of rivaroxaban versus use of warfarin for the treatment of patients with non-valvular AF at moderate to high risk.

          Methods

          A Markov model was designed and populated with local cost estimates, safety-on-treatment clinical results from the pivotal phase III ROCKET AF trial and utility values obtained from the literature.

          Results

          Rivaroxaban treatment was associated with fewer ischemic strokes and systemic embolisms (0.308 vs. 0.321 events), intracranial bleeds (0.048 vs. 0.063), and myocardial infarctions (0.082 vs. 0.095) per patient compared with warfarin. Over a lifetime time horizon, rivaroxaban led to a reduction of 0.042 life-threatening events per patient, and increases of 0.111 life-years and 0.094 quality-adjusted life-years (QALYs) versus warfarin treatment. This resulted in an incremental cost-effectiveness ratio of €8,809 per QALY or €7,493 per life-year gained. These results are based on valuated data from 2010. Sensitivity analysis indicated that these results were robust and that rivaroxaban is cost-effective compared with warfarin in 87 % of cases should a willingness-to-pay threshold of €35,000/QALY gained be considered.

          Conclusions

          The present analysis suggests that rivaroxaban is a cost-effective alternative to warfarin therapy for the prevention of stroke in patients with AF in the Belgian healthcare setting.

          Electronic supplementary material

          The online version of this article (doi:10.1007/s40273-013-0087-9) contains supplementary material, which is available to authorized users.

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          Decision Modelling for Health Economic Evaluation

          Andrew H Briggs, Karl Claxton, Mark J Sculpher (2006)
          In financially constrained health systems across the world, increasing emphasis is being placed on the ability to demonstrate that health care interventions are not only effective, but also cost-effective. This book deals with decision modelling techniques that can be used to estimate the value for money of various interventions including medical devices, surgical procedures, diagnostic technologies, and pharmaceuticals. Particular emphasis is placed on the importance of the appropriate representation of uncertainty in the evaluative process and the implication this uncertainty has for decision making and the need for future research. This highly practical guide takes the reader through the key principles and approaches of modelling techniques. It begins with the basics of constructing different forms of the model, the population of the model with input parameter estimates, analysis of the results, and progression to the holistic view of models as a valuable tool for informing future research exercises. Case studies and exercises are supported with online templates and solutions. This book will help analysts understand the contribution of decision-analytic modelling to the evaluation of health care programmes. [Ed.]
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            Effect of intensity of oral anticoagulation on stroke severity and mortality in atrial fibrillation.

            Elaine Hylek, Alan S Go, Yuchiao Chang … (2003)
            The incidence of stroke in patients with atrial fibrillation is greatly reduced by oral anticoagulation, with the full effect seen at international normalized ratio (INR) values of 2.0 or greater. The effect of the intensity of oral anticoagulation on the severity of atrial fibrillation-related stroke is not known but is central to the choice of the target INR. We studied incident ischemic strokes in a cohort of 13,559 patients with nonvalvular atrial fibrillation. Strokes were identified through hospitalization data bases and validated on the basis of medical records, which also provided information on the use of warfarin or aspirin, the INR at admission, and coexisting illnesses. The severity of stroke was graded according to a modified Rankin scale. Thirty-day mortality was ascertained from hospitalization and mortality files. Of 596 ischemic strokes, 32 percent occurred during warfarin therapy, 27 percent during aspirin therapy, and 42 percent during neither type of therapy. Among patients who were taking warfarin, an INR of less than 2.0 at admission, as compared with an INR of 2.0 or greater, independently increased the odds of a severe stroke in a proportional-odds logistic-regression model (odds ratio, 1.9; 95 percent confidence interval, 1.1 to 3.4) across three severity categories and the risk of death within 30 days (hazard ratio, 3.4; 95 percent confidence interval, 1.1 to 10.1). An INR of 1.5 to 1.9 at admission was associated with a mortality rate similar to that for an INR of less than 1.5 (18 percent and 15 percent, respectively). The 30-day mortality rate among patients who were taking aspirin at the time of the stroke was similar to that among patients who were taking warfarin and who had an INR of less than 2.0. Among patients with nonvalvular atrial fibrillation, anticoagulation that results in an INR of 2.0 or greater reduces not only the frequency of ischemic stroke but also its severity and the risk of death from stroke. Our findings provide further evidence against the use of lower INR target levels in patients with atrial fibrillation. Copyright 2003 Massachusetts Medical Society
            Article 0 comments Cited 196 times – based on 0 reviews     Review now
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              Atrial fibrillation: a major contributor to stroke in the elderly. The Framingham Study.

              P A Wolf (1987)
              Chronic atrial fibrillation without valvular disease has been associated with increased stroke incidence. The impact of atrial fibrillation on the risk of stroke with increasing age was examined in 5184 men and women in the Framingham Heart Study. After 30 years of follow-up, chronic atrial fibrillation appeared in 303 persons. Age-specific incidence rates steadily increased from 0.2 per 1000 for ages 30 to 39 years to 39.0 per 1000 for ages 80 to 89 years. The proportion of strokes associated with this arrhythmia was 14.7%, 68 of the total 462 initial strokes, increasing steadily with age from 6.7% for ages 50 to 59 years to 36.2% for ages 80 to 89 years. In contrast to the impact of cardiac failure, coronary heart disease, and hypertension, which declined with age, atrial fibrillation was a significant contributor to stroke at all ages.
              Article 0 comments Cited 153 times – based on 0 reviews     Review now
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                Author and article information

                Contributors
                : +32-2-5356394 , +32-2-7251955 , mimi.deruyck@bayer.com
                Journal
                Journal ID (nlm-ta): Pharmacoeconomics
                Journal ID (iso-abbrev): Pharmacoeconomics
                Title: Pharmacoeconomics
                Publisher: Springer International Publishing (Cham )
                ISSN (Print): 1170-7690
                ISSN (Electronic): 1179-2027
                Publication date (Electronic): 13 September 2013
                Publication date PMC-release: 13 September 2013
                Publication date (Print): 2013
                Volume: 31
                Pages: 909-918
                Affiliations
                [ ]Deloitte Health Economics and Outcomes Research Group, Brussels, Belgium
                [ ]Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
                [ ]Laboratory of Neurobiology, Vesalius Research Center, VIB, Leuven, Belgium
                [ ]Experimental Neurology (Department of Neurosciences) and Leuven Research Institute for Neuroscience and Disease (LIND), University of Leuven (KU Leuven), Leuven, Belgium
                [ ]Department of Neurology, University Hospitals Leuven, Leuven, Belgium
                [ ]Mariaziekenhuis Noord-Limburg, Overpelt, Belgium
                [ ]Department of Internal Medicine (Cardiovascular Diseases), Faculty of Medicine and Health Sciences, Ghent University and Ghent University Hospital, Ghent, Belgium
                [ ]Department of Public Health, Faculty of Medicine and Health Sciences, Ghent University and Ghent University Hospital, Ghent, Belgium
                [ ]IMS Health, London, UK
                [ ]Global Market Access/HEOR, Bayer HealthCare, Wuppertal, Germany
                [ ]Market Access Department, Bayer HealthCare, J.E. Mommaertslaan 14, 1831 Diegem (Machelen), Belgium
                Article
                Publisher ID: 87
                DOI: 10.1007/s40273-013-0087-9
                PMC ID: 3824571
                PubMed ID: 24030788
                SO-VID: c222eef7-94b9-4d4e-8c63-d852bcecdcdb
                Copyright © © The Author(s) 2013
                License:

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and the source are credited.

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                Subject: Original Research Article
                Custom metadata
                issue-copyright-statement © Springer International Publishing Switzerland 2013

                ScienceOpen disciplines: Economics of health & social care
                Data availability:
                ScienceOpen disciplines: Economics of health & social care

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