title: Cost-effectiveness analysis of extended duration anticoagulation with rivaroxaban to prevent recurrent venous thromboembolism.
abstract: BACKGROUND
  Extended duration anticoagulation with rivaroxaban for an additional 6-12 months can reduce recurrent venous thromboembolic events (VTE) compared to placebo by ~82%, but at the detriment of increased bleeding. We sought to estimate the cost-effectiveness of extended duration prophylaxis of recurrent VTE with rivaroxaban.
  
  
  METHODS
  A Markov model was developed to estimate the cost-effectiveness of extended duration rivaroxaban, 20mg daily, compared to placebo using a Medicare perspective, a one-monthcycle length and a 40-year time horizon. The model assumed a cohort of 58-year-old patients who had already completed an initial 6-12 months of anticoagulation with rivaroxaban or a vitamin K antagonist; and whom prescribers had clinical equipoise with respect to the need for continued anticoagulation. Data sources included EINSTEIN-Extension and other published studies of VTE. Outcomes included direct treatment costs (in 2013US$), quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios (ICERs).
  
  
  RESULTS
  Extended duration rivaroxaban resulted in higher treatment costs ($22,645 vs. $22,083) but yielded greater QALYs (16.167 vs. 16.134) as compared to placebo; corresponding to an ICER of $17,030/QALY gained. Our model was most sensitive to the baseline risk of bleeding and recurrent VTE, the hazard ratio of developing a recurrent event while on rivaroxaban and time horizon. Monte Carlo Simulation suggested rivaroxaban would be cost-effective in 66% of 10,000 iterations, assuming a willingness-to-pay threshold of $50,000/QALY.
  
  
  CONCLUSIONS
  Despite the cost of rivaroxaban and an increased risk of bleeding, extending VTE treatment for an additional 6-12 months with rivaroxaban was found cost-effective compared to the placebo over a 40-year time horizon.
authors.affiliation: University of Connecticut School of Pharmacy, Storrs, CT, USA. Electronic address: craig.coleman@hhchealth.org.
authors.forename: Craig I
authors.initials: CI
authors.lastname: Coleman
authors.affiliation: University of Connecticut School of Pharmacy, Storrs, CT, USA.
authors.forename: Brendan L
authors.initials: BL
authors.lastname: Limone
authors.affiliation: Janssen Scientific Affairs, Raritan, NJ, USA.
authors.forename: Brahim K
authors.initials: BK
authors.lastname: Bookhart
authors.affiliation: Janssen Scientific Affairs, Raritan, NJ, USA.
authors.forename: Samir H
authors.initials: SH
authors.lastname: Mody
authors.affiliation: University of Illinois at Chicago College of Pharmacy and University of Illinois Hospital and Health Sciences System, Chicago, IL; USA.
authors.forename: Edith A
authors.initials: EA
authors.lastname: Nutescu
mesh_terms: D000925:Anticoagulants / Q000008:administration & dosage* / Q000191:economics; D015331:Cohort Studies; D003362:Cost-Benefit Analysis; D005260:Female; D006801:Humans; D008297:Male; D008390:Markov Chains; D008875:Middle Aged; D018803:Models, Economic; D009025:Morpholines / Q000008:administration & dosage* / Q000191:economics*; D000069552:Rivaroxaban; D013876:Thiophenes / Q000008:administration & dosage* / Q000191:economics*; D014481:United States; D054556:Venous Thromboembolism / Q000188:drug therapy / Q000191:economics / Q000517:prevention & control*
chemical_list: D000925:Anticoagulants; D009025:Morpholines; D013876:Thiophenes; D000069552:Rivaroxaban
keywords: Anticoagulation; Cost-effectiveness analysis; Extended treatment; Markov model; Rivaroxaban; Venous thromboembolism