title: A Decision Analysis of Percutaneous Left Atrial Appendage Occlusion Relative to Novel and Traditional Oral Anticoagulation for Stroke Prevention in Patients with New-Onset Atrial Fibrillation.
abstract: Percutaneous left atrial appendage occlusion (LAAO) is a nonpharmacologic approach for stroke prevention in nonvalvular atrial fibrillation (NVAF). No direct comparisons to novel oral anticoagulants (OACs) exists, limiting decision making on the optimal strategy for stroke prevention in NVAF patients. Addressing this gap in knowledge is timely given the recent debate by the US Food and Drug Administration regarding the effectiveness of LAAO.
  
  
  
  To assess the cost-effectiveness of LAAO and novel OACs relative to warfarin in patients with new-onset NVAF without contraindications to OAC.
  
  
  
  A cost-utility analysis using a patient-level Markov micro-simulation decision analytic model was undertaken to determine the lifetime costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio (ICER) of LAAO and all novel OACs relative to warfarin. Effectiveness and utility data were obtained from the published literature and cost from the Ontario Drug Benefits Formulary and Case Costing Initiative.
  
  
  
  Warfarin had the lowest discounted QALY (5.13 QALYs), followed by dabigatran (5.18 QALYs), rivaroxaban and LAAO (5.21 QALYs), and apixaban (5.25 QALYs). The average discounted lifetime costs were $15 776 for warfarin, $18 280 for rivaroxaban, $19 156 for apixaban, $20 794 for dabigatran, and $21 789 for LAAO. Apixaban dominated dabigatran and LAAO and demonstrated extended dominance over rivaroxaban. The ICER for apixaban relative to warfarin was $28 167/QALY. Apixaban was preferred in 40.2% of simulations at a willingness-to-pay threshold of $50 000/QALY.
  
  
  
  Assumptions regarding clinical and methodological differences between published studies of each therapy were minimized.
  
  
  
  Apixaban is the most cost-effective therapy for stroke prevention in patients with new-onset NVAF without contraindications to OAC. Uncertainty around this conclusion exists, highlighting the need for further research.
authors.affiliation: Faculty of Medicine, University of Ottawa, Ontario, Canada (AM)
authors.forename: Andrew
authors.initials: A
authors.lastname: Micieli
authors.affiliation: Schulich Heart Centre, Sunnybrook Health Sciences Centre, Faculty of Medicine, University of Toronto, Ontario, Canada (HCW, SMS)|Institute of Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada (HCW)|Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada (HCW, FQ, CLA)
authors.forename: Harindra C
authors.initials: HC
authors.lastname: Wijeysundera
authors.affiliation: Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada (HCW, FQ, CLA)
authors.forename: Feng
authors.initials: F
authors.lastname: Qiu
authors.affiliation: Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada (HCW, FQ, CLA)|Division of Emergency Medicine, Faculty of Medicine, University of Toronto, Ontario, Canada (CLA).
authors.forename: Clare L
authors.initials: CL
authors.lastname: Atzema
authors.affiliation: Faculty of Medicine, University of Ottawa, Ontario, Canada (AM)|Schulich Heart Centre, Sunnybrook Health Sciences Centre, Faculty of Medicine, University of Toronto, Ontario, Canada (HCW, SMS)
authors.forename: Sheldon M
authors.initials: SM
authors.lastname: Singh
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000008:administration & dosage* / Q000191:economics; D020517:Atrial Appendage; D001281:Atrial Fibrillation; D000066491:Clinical Decision-Making; D003362:Cost-Benefit Analysis; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009864:Ontario; D019057:Quality-Adjusted Life Years; D020521:Stroke / Q000517:prevention & control*; D060205:Therapeutic Occlusion
chemical_list: D000925:Anticoagulants
keywords: anticoagulants; atrial appendage; atrial fibrillation; bleeding; prevention; stroke