title: Common flaws exist in published cost-effectiveness models of pharmacologic stroke prevention in atrial fibrillation.
abstract: OBJECTIVE
  Decision makers use models to assist in evaluating the cost-effectiveness of pharmacologic stroke prevention in atrial fibrillation (SPAF).
  
  
  METHODS
  We performed a search of databases through October 3, 2012 to identify pharmacologic SPAF cost-effectiveness models.
  
  
  RESULTS
  Of 30 identified models, 28 included warfarin, but only 60% assessed the impact of warfarin control on conclusions. Aspirin, dual antiplatelet, and newer anticoagulants were included in 41%, 10%, and 63% of models, respectively. Models used similar structures but included varying health states and made varying assumptions. They rarely reported performing a literature search to identify anticoagulant-specific inputs and used similar and older sources. Sixteen models used a lone randomized trial to reflect the efficacy and safety of main comparisons. One-third of models claimed a societal perspective; however, none included indirect costs. Patients typically initiated anticoagulation in the sixth or seventh decade of life and are followed for their lifetimes. Almost 70% of incremental cost-effectiveness ratios were below reported willingness-to-pay thresholds. All used deterministic sensitivity analyses and 77% conducted Monte Carlo simulation. Less than half of the models were rated "high quality," yet were frequently published in high-impact journals.
  
  
  CONCLUSIONS
  Pharmacologic SPAF cost-effectiveness models have been extensively reported, but many may have flaws giving reason for decision makers to use caution. We provide 10 recommendations to avoid common flaws in SPAF cost-effectiveness models.
authors.affiliation: Evidence-Based Practice Center, Hartford Hospital, 80 Seymour Street, Hartford, CT 06102, USA; University of Connecticut School of Pharmacy, 69 North Eagleville Road, Storrs, CT 06102, USA.
authors.forename: Brendan L
authors.initials: BL
authors.lastname: Limone
authors.affiliation: University of Connecticut School of Pharmacy, 69 North Eagleville Road, Storrs, CT 06102, USA.
authors.forename: William L
authors.initials: WL
authors.lastname: Baker
authors.affiliation: Evidence-Based Practice Center, Hartford Hospital, 80 Seymour Street, Hartford, CT 06102, USA; University of Connecticut School of Pharmacy, 69 North Eagleville Road, Storrs, CT 06102, USA.
authors.forename: Elizabeth S
authors.initials: ES
authors.lastname: Mearns
authors.affiliation: Evidence-Based Practice Center, Hartford Hospital, 80 Seymour Street, Hartford, CT 06102, USA; University of Connecticut School of Pharmacy, 69 North Eagleville Road, Storrs, CT 06102, USA.
authors.forename: C Michael
authors.initials: CM
authors.lastname: White
authors.affiliation: Department of Cardiology, Hartford Hospital, Hartford, CT 06102, USA.
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Kluger
authors.affiliation: Evidence-Based Practice Center, Hartford Hospital, 80 Seymour Street, Hartford, CT 06102, USA; University of Connecticut School of Pharmacy, 69 North Eagleville Road, Storrs, CT 06102, USA. Electronic address: craig.coleman@hhchealth.org.
authors.forename: Craig I
authors.initials: CI
authors.lastname: Coleman
mesh_terms: D000925:Anticoagulants / Q000191:economics* / Q000627:therapeutic use; D001281:Atrial Fibrillation / Q000188:drug therapy*; D003362:Cost-Benefit Analysis; D006801:Humans; D018803:Models, Economic; D011643:Publishing / Q000592:standards* / Q000706:statistics & numerical data; D016032:Randomized Controlled Trials as Topic; D020521:Stroke / Q000517:prevention & control*; D014859:Warfarin / Q000191:economics / Q000627:therapeutic use
chemical_list: D000925:Anticoagulants; D014859:Warfarin
keywords: Anticoagulants; Atrial fibrillation; Cost effectiveness; Decision modeling; Economics; Markov model; Medical