Should hemodialysis patients with atrial fibrillation undergo systemic anticoagulation? A cost-utility analysis.
BACKGROUND
Approximately 14% of hemodialysis patients have atrial fibrillation. Hemodialysis patients with atrial fibrillation appear to be at increased risk of both thromboembolic complications and bleeding. Furthermore, there is uncertainty regarding the efficacy of warfarin or acetylsalicylic acid (ASA) therapy for preventing strokes in this subgroup because they were excluded from relevant trials.


METHODS
We performed a cost-utility analysis. Probabilistic sensitivity analysis was used to incorporate parameter uncertainty into the model. Expected value of perfect information and scenario analyses were performed to identify the important drivers of the decision and focus future research.


METHODS
Base case was a 60-year-old male hemodialysis patient in the United States.


METHODS
A Markov Monte Carlo microsimulation model was constructed from the perspective of the health care payer, and patients were followed up during their lifetime.


METHODS
We compared 3 alternative treatment strategies for permanent atrial fibrillation in hemodialysis patients: warfarin, ASA, or no treatment.


RESULTS
Quality-adjusted survival and cost.


RESULTS
ASA and warfarin both prolonged survival compared with no treatment (0.06 and 0.15 quality-adjusted life-years [QALYs], respectively). ASA was associated with an incremental cost-effectiveness ratio of $82,100/QALY. Warfarin provided additional benefits at a cost of $88,400 for each QALY gained relative to ASA. At a threshold of $100,000/QALY, the probabilities that no treatment, warfarin, and ASA were the most efficient therapy were 20%, 58%, and 23%, respectively.


CONCLUSIONS
Parameterization data and costs were taken from US studies and may not be generalizable to other countries. Peritoneal dialysis patients were not included in the analysis.


CONCLUSIONS
The high future cost of hemodialysis constrains incremental cost-effectiveness ratios to values greater than commonly cited thresholds ($50,000/QALY). Based on available evidence, warfarin appears to be the optimal therapy to prevent thromboembolic stroke in hemodialysis patients with atrial fibrillation. Additional study is required to determine the efficacy of warfarin and risk of bleeding complications in this population so that patients can make a more informed choice.
Quinn
Robert R
RR
Department of Medicine, Division of Nephrology, Sunnybrook Health Sciences Centre, Toronto, Canada. robert.quinn@sunnybrook.ca
Naimark
David M J
DM
Oliver
Matthew J
MJ
Bayoumi
Ahmed M
AM
D000925:Anticoagulants / Q000191:economics* / Q000627:therapeutic use*; D001241:Aspirin / Q000191:economics* / Q000627:therapeutic use*; D001281:Atrial Fibrillation / Q000188:drug therapy* / Q000191:economics*; D003362:Cost-Benefit Analysis; D006801:Humans; D008297:Male; D008875:Middle Aged; D010975:Platelet Aggregation Inhibitors / Q000191:economics* / Q000627:therapeutic use*; D006435:Renal Dialysis; D014859:Warfarin / Q000191:economics* / Q000627:therapeutic use*
D000925:Anticoagulants; D010975:Platelet Aggregation Inhibitors; D014859:Warfarin; D001241:Aspirin