title: Cost-Effectiveness of Dabigatran (150 mg Twice Daily) and Warfarin in Patients ≥ 65 Years With Nonvalvular Atrial Fibrillation.
abstract: Dabigatran has been shown to be superior to warfarin for stroke prevention in nonvalvular atrial fibrillation (NVAF) but with higher out-of-pocket costs for patients. Although dabigatran has been shown to be cost effective from a societal perspective, cost implications for individual patients and insurers are not well described. We aimed to assess cost perspectives of each payer (Medicare and patient) in relation to administration, monitoring, and adverse outcomes for dabigatran and warfarin in patients with and without prescription drug coverage. Using a Markov model, we performed a decision analysis comparing 2 treatment strategies (dose-adjusted warfarin and dabigatran 150 mg twice daily) in patients 65 years old with NVAF, CHADS2 scores ≥ 1, and Medicare insurance. Patients have a quality-adjusted life expectancy of 8.998 quality-adjusted life years with warfarin and 9.39 quality-adjusted life years with dabigatran 150 mg twice daily. From Medicare's perspective, the incremental cost-effectiveness ratio comparing dabigatran with warfarin was $35,311 for patients with Part D coverage and cost saving for patients without coverage. From the patient's perspective, the incremental cost-effectiveness ratio comparing dabigatran with warfarin was cost saving for patients with Part D coverage and $63,884 for those without coverage. In patients ≥ 65 years with NVAF and prescription insurance coverage, dabigatran 150 mg twice daily is both cost effective (Medicare's perspective) and cost saving (patient perspective) compared with warfarin, at a willingness-to-pay threshold of $100,000. However, patients without prescription drug coverage have a high out-of-pocket cost burden with dabigatran therapy, leading to a reduction in its cost-effectiveness compared with warfarin therapy. In conclusion, this Markov model suggests that Medicare Part D coverage influences the cost-effectiveness of dabigatran 150 mg daily compared with dose-adjusted warfarin from multiple payer perspectives.
authors.affiliation: Department of Internal Medicine, New York Presbyterian/Weill Cornell Medical Center, New York, New York.
authors.forename: Brian M
authors.initials: BM
authors.lastname: Salata
authors.affiliation: University of Michigan School of Public Health, Ann Arbor, Michigan; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan.
authors.forename: David W
authors.initials: DW
authors.lastname: Hutton
authors.affiliation: Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan; Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan; Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan; Department of Neurology and Stroke Program, University of Michigan, Ann Arbor, Michigan.
authors.forename: Deborah A
authors.initials: DA
authors.lastname: Levine
authors.affiliation: Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan; University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan.
authors.forename: James B
authors.initials: JB
authors.lastname: Froehlich
authors.affiliation: Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan; University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan. Electronic address: gbarnes@med.umich.edu.
authors.forename: Geoffrey D
authors.initials: GD
authors.lastname: Barnes
mesh_terms: D000368:Aged; D000925:Anticoagulants / Q000008:administration & dosage / Q000191:economics; D000991:Antithrombins / Q000008:administration & dosage / Q000191:economics; D001281:Atrial Fibrillation / Q000150:complications / Q000188:drug therapy* / Q000191:economics; D002545:Brain Ischemia / Q000191:economics / Q000209:etiology / Q000517:prevention & control*; D003362:Cost-Benefit Analysis; D000069604:Dabigatran / Q000008:administration & dosage* / Q000191:economics; D004305:Dose-Response Relationship, Drug; D016527:Drug Costs; D005260:Female; D005102:Health Expenditures; D006801:Humans; D008297:Male; D012189:Retrospective Studies; D014481:United States; D014859:Warfarin / Q000008:administration & dosage* / Q000191:economics
chemical_list: D000925:Anticoagulants; D000991:Antithrombins; D014859:Warfarin; D000069604:Dabigatran