title: Cost-effectiveness of preference-based antithrombotic therapy for patients with nonvalvular atrial fibrillation.
abstract: OBJECTIVE
  Recent atrial fibrillation guidelines recommend the incorporation of patient preferences into the selection of antithrombotic therapy. However, no trial has examined how incorporating such preferences would affect quality-adjusted survival or medical expenditure. We compared 10-year projections of quality-adjusted survival and medical expenditure associated with two atrial fibrillation treatment strategies: warfarin-for-all therapy versus preference-based therapy. The preference-based strategy prescribed whichever antithrombotic therapy, warfarin or aspirin, had the greater projected quality-adjusted survival.
  
  
  METHODS
  We used decision analysis stratified by the number of stroke risk factors (history of stroke, transient ischemic attack, hypertension, diabetes, or heart disease). The base case focused on compliant 65-year-old patients who had nonvalvular atrial fibrillation and no contraindications to antithrombotic therapy.
  
  
  RESULTS
  In patients whose only risk factor for stroke was atrial fibrillation, preference-based therapy improved projected quality-adjusted survival by 0.05 quality-adjusted life year (QALY) and saved $670. For patients who had atrial fibrillation and one additional risk factor for stroke, preference-based therapy improved quality-adjusted survival by 0.02 QALY and saved $90. In patients who had atrial fibrillation and multiple additional risk factors for stroke, preference-based therapy increased medical expenditures and did not improve quality-adjusted survival substantially. The benefits of preference-flexible therapy arose from the minority of patients who would have had a longer quality-adjusted survival if they had been prescribed aspirin rather than warfarin.
  
  
  CONCLUSIONS
  As do risks of stroke and of hemorrhage, patients' preferences help to determine which antithrombotic therapy is optimal. Preference-based treatment should improve quality-adjusted survival and reduce medical expenditure in patients who have nonvalvular atrial fibrillation and not more than one additional risk factor for stroke.
authors.affiliation: Division of General Medical Sciences, Washington University, St Louis, Mo., USA. gage@osler.wustl.edu
authors.forename: B F
authors.initials: BF
authors.lastname: Gage
authors.forename: A B
authors.initials: AB
authors.lastname: Cardinalli
authors.forename: D K
authors.initials: DK
authors.lastname: Owens
mesh_terms: D000368:Aged; D000925:Anticoagulants / Q000008:administration & dosage; D001241:Aspirin / Q000008:administration & dosage; D001281:Atrial Fibrillation / Q000150:complications / Q000188:drug therapy* / Q000523:psychology; D002561:Cerebrovascular Disorders / Q000209:etiology / Q000401:mortality / Q000517:prevention & control*; D015331:Cohort Studies; D003362:Cost-Benefit Analysis; D003663:Decision Trees; D004617:Embolism / Q000150:complications; D005260:Female; D017048:Health Care Costs; D006801:Humans; D008297:Male; D008875:Middle Aged; D017060:Patient Satisfaction; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage; D019057:Quality-Adjusted Life Years; D012307:Risk Factors; D012680:Sensitivity and Specificity; D015912:Thrombolytic Therapy / Q000191:economics*; D014859:Warfarin / Q000008:administration & dosage
chemical_list: D000925:Anticoagulants; D010975:Platelet Aggregation Inhibitors; D014859:Warfarin; D001241:Aspirin