Cost-effectiveness of different strategies for stroke prevention in patients with atrial fibrillation in a health resource-limited setting.
OBJECTIVE
To compare the lifetime cost and effectiveness of five alternative chronic atrial fibrillation (AF) management strategies: rivaroxaban, warfarin, aspirin plus clopidogrel, aspirin and no prevention.


METHODS
An individual-level state-transition model was developed to track the lifetime disease course associated with AF. The clinical and utility data were derived from published studies. The cost data were estimated based on local charges and current Chinese practices. Sensitivity analyses were used to explore the impact of uncertainty on the results.


RESULTS
For base-case patients with a CHADS2 score of 3, the cost per additional quality-adjusted life-years (QALYs) gained for rivaroxaban compared with no prevention, aspirin, aspirin plus clopidogrel and warfarin was $116,884, $153,944, $155,979 and $216,273, respectively. CHADS2 score had a substantial impact on the model outcomes for different prevention strategies. The time distribution of warfarin international normalised ratio (INR), stroke and intracranial haemorrhage (ICH) risks, cost of rivaroxaban and utility of warfarin therapy had substantial impacts on the results. Based on a willingness-to-pay threshold of $16,350/QALY, no prevention strategy was the preferred therapy for a patient with a low risk for stroke and a high risk for ICH; aspirin was preferred for patients with a moderate risk for stroke and ICH; and warfarin was preferred for patients with a high risk for stroke and a low risk of ICH.


CONCLUSIONS
In the context of limited health resources, rivaroxaban is unlikely to be cost-effective, although it provided more health benefits comparing with other strategies. Additionally, warfarin with good INR control might be more suitable for AF patients in developing regions.
Clinical Outcomes and Economics Group, Department of pharmacy, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.
Bin
B
Wu
Li
L
Kun
Xiaoyan
X
Liu
Ben
B
He
D000925:Anticoagulants / Q000191:economics / Q000627:therapeutic use*; D001241:Aspirin / Q000008:administration & dosage / Q000191:economics / Q000627:therapeutic use; D001281:Atrial Fibrillation / Q000188:drug therapy* / Q000191:economics; D002681:China; D000077144:Clopidogrel; D003362:Cost-Benefit Analysis; D004359:Drug Therapy, Combination; D006801:Humans; D018803:Models, Economic; D009025:Morpholines / Q000191:economics / Q000627:therapeutic use; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage / Q000191:economics / Q000627:therapeutic use*; D019057:Quality-Adjusted Life Years; D012307:Risk Factors; D000069552:Rivaroxaban; D020521:Stroke / Q000191:economics / Q000517:prevention & control*; D013876:Thiophenes / Q000191:economics / Q000627:therapeutic use; D013988:Ticlopidine / Q000008:administration & dosage / Q000031:analogs & derivatives / Q000191:economics / Q000627:therapeutic use; D014859:Warfarin / Q000191:economics / Q000627:therapeutic use
D000925:Anticoagulants; D009025:Morpholines; D010975:Platelet Aggregation Inhibitors; D013876:Thiophenes; D014859:Warfarin; D000069552:Rivaroxaban; D000077144:Clopidogrel; D013988:Ticlopidine; D001241:Aspirin