title: Review of economics and cost-effectiveness analyses of anticoagulant therapy for stroke prevention in atrial fibrillation in the US.
abstract: OBJECTIVE
  To summarize the available evidence on the issues in health economics related to oral anticoagulation for stroke prevention in atrial fibrillation (AF) in the US.
  
  
  METHODS
  A literature review was performed using PubMed, EMBASE, Cochrane Library, and International Pharmaceutical Abstracts, as well as the websites of professional organizations.
  
  
  METHODS
  The search was conducted according to a prespecified protocol, limiting articles to those published in English from 2001 to October 2012 and focused on the economics associated with AF and AF-related stroke in the US. Data from 27 studies were extracted and included in the review.
  
  
  RESULTS
  Strokes in patients with AF are more debilitating and have higher recurrence rates and mortality compared with strokes unrelated to AF. However, data describing the long-term cost of AF-related stroke and stroke subtypes remain limited. The costs of major gastrointestinal (GI) bleeding and intracranial bleeding related to warfarin are significant, whereas the costs of the more frequent minor GI bleeding are relatively low. Overall, the cost-effectiveness of warfarin versus aspirin or no treatment in patients with at least 1 risk factor for stroke is well established. Economic evaluations based on results from randomized controlled clinical trials generally found that new anticoagulants were a cost-effective alternative to warfarin for stroke prevention in AF. However, these cost-effectiveness results are highly sensitive to how well optimal international normalized ratio control is maintained (within target of 2.0-3.0) for warfarin and the time horizon used for analysis. Time in therapeutic range for warfarin in routine clinical practice was lower than in clinical trials, as shown by previous studies.
  
  
  CONCLUSIONS
  This review identified several areas of uncertainty regarding the economic benefit of anticoagulants. The generalizability of cost-effectiveness results of anticoagulant therapy in AF based on clinical trial data must be confirmed by comparative effectiveness research conducted in the real-world setting.
authors.affiliation: RTI Health Solutions, Lund, Sweden. bscheele@rti.org
authors.forename: Birgitta
authors.initials: B
authors.lastname: von Schéele
authors.forename: Maria
authors.initials: M
authors.lastname: Fernandez
authors.forename: Susan Lynn
authors.initials: SL
authors.lastname: Hogue
authors.forename: Winghan Jacqueline
authors.initials: WJ
authors.lastname: Kwong
mesh_terms: D000925:Anticoagulants / Q000009:adverse effects* / Q000191:economics*; D001281:Atrial Fibrillation / Q000150:complications*; D003362:Cost-Benefit Analysis; D006470:Hemorrhage / Q000139:chemically induced / Q000191:economics; D006801:Humans; D008390:Markov Chains; D019057:Quality-Adjusted Life Years; D016032:Randomized Controlled Trials as Topic; D012008:Recurrence; D012307:Risk Factors; D020521:Stroke / Q000191:economics* / Q000517:prevention & control*; D014481:United States
chemical_list: D000925:Anticoagulants