Cost-effectiveness of self-managed versus physician-managed oral anticoagulation therapy.
BACKGROUND
Patient self-management of long-term oral anticoagulation therapy is an effective strategy in a number of clinical situations, but it is currently not a funded option in the Canadian health care system. We sought to compare the incremental cost and health benefits of self-management with those of physician management from the perspective of the Canadian health care payer over a 5-year period.


METHODS
We developed a Bayesian Markov model comparing the costs and quality-adjusted life years (QALYs) accrued to patients receiving oral anticoagulation therapy through self-management or physician management for atrial fibrillation or for a mechanical heart valve. Five health states were defined: no events, minor hemorrhagic events, major hemorrhagic events, thrombotic events and death. Data from published literature were used for transition probabilities. Canadian 2003 costs were used, and utility estimates were obtained from various published sources.


RESULTS
Self-management resulted in 3.50 fewer thrombotic events, 0.78 fewer major hemorrhagic events and 0.12 fewer deaths per 100 patients than physician management. The average discounted incremental cost of self-management over physician management was found to be 989 dollars (95% confidence interval [CI] 310 dollars-1655 dollars) per patient and the incremental QALYs gained was 0.07 (95% CI 0.06-0.08). The cost-effectiveness of self-management was 14,129 dollars per QALY gained. There was a 95% chance that self-management would be cost-effective at a willingness to pay of 23,800 dollars per QALY. Results were robust in probabilistic and deterministic sensitivity analyses.


CONCLUSIONS
This model suggests that self-management is a cost-effective strategy for those receiving long-term oral anticoagulation therapy for atrial fibrillation or for a mechanical heart valve.
Regier
Dean A
DA
Collaboration for Outcomes Research and Evaluation, Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, BC.
Sunderji
Rubina
R
Lynd
Larry D
LD
Gin
Kenneth
K
Marra
Carlo A
CA
D000284:Administration, Oral; D000925:Anticoagulants / Q000008:administration & dosage* / Q000009:adverse effects / Q000191:economics; D001281:Atrial Fibrillation / Q000188:drug therapy* / Q000191:economics*; D001499:Bayes Theorem; D002170:Canada; D017281:Cost of Illness; D003362:Cost-Benefit Analysis; D006302:Health Services Research; D006350:Heart Valve Prosthesis / Q000191:economics*; D006801:Humans; D019934:International Normalized Ratio; D008390:Markov Chains; D009313:National Health Programs; D017063:Outcome Assessment, Health Care; D010819:Physician's Role; D019057:Quality-Adjusted Life Years; D012646:Self Administration / Q000191:economics*
D000925:Anticoagulants