title: Cost-effectiveness of non-vitamin K antagonist oral anticoagulants for atrial fibrillation in Portugal.
abstract: OBJECTIVE
  Recently, three novel non-vitamin K antagonist oral anticoagulants received approval for reimbursement in Portugal for patients with non-valvular atrial fibrillation (AF). It is therefore important to evaluate the relative cost-effectiveness of these new oral anticoagulants in Portuguese AF patients.
  
  
  METHODS
  A Markov model was used to analyze disease progression over a lifetime horizon. Relative efficacy data for stroke (ischemic and hemorrhagic), bleeding (intracranial, other major bleeding and clinically relevant non-major bleeding), myocardial infarction and treatment discontinuation were obtained by pairwise indirect comparisons between apixaban, dabigatran and rivaroxaban using warfarin as a common comparator. Data on resource use were obtained from the database of diagnosis-related groups and an expert panel. Model outputs included life years gained, quality-adjusted life years (QALYs), direct healthcare costs and incremental cost-effectiveness ratios (ICERs).
  
  
  RESULTS
  Apixaban provided the most life years gained and QALYs. The ICERs of apixaban compared to warfarin and dabigatran were €5529/QALY and €9163/QALY, respectively. Apixaban was dominant over rivaroxaban (greater health gains and lower costs). The results were robust over a wide range of inputs in sensitivity analyses. Apixaban had a 70% probability of being cost-effective (at a threshold of €20 000/QALY) compared to all the other therapeutic options.
  
  
  CONCLUSIONS
  Apixaban is a cost-effective alternative to warfarin and dabigatran and is dominant over rivaroxaban in AF patients from the perspective of the Portuguese national healthcare system. These conclusions are based on indirect comparisons, but despite this limitation, the information is useful for healthcare decision-makers.
authors.affiliation: Centro de Estudos de Medicina Baseada na Evidência, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal; Laboratório de Farmacologia Clínica e Terapêutica, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal; Unidade de Farmacologia Clínica, Instituto de Medicina Molecular, Lisboa, Portugal. Electronic address: jncosta@medicina.ulisboa.pt.
authors.forename: João
authors.initials: J
authors.lastname: Costa
authors.affiliation: Centro de Estudos de Medicina Baseada na Evidência, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal.
authors.forename: Francesca
authors.initials: F
authors.lastname: Fiorentino
authors.affiliation: Laboratório de Farmacologia Clínica e Terapêutica, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal; Unidade de Farmacologia Clínica, Instituto de Medicina Molecular, Lisboa, Portugal; Serviço de Cardiologia, Hospital Garcia de Orta, Almada, Portugal.
authors.forename: Daniel
authors.initials: D
authors.lastname: Caldeira
authors.affiliation: Health & Value Department, Laboratórios Pfizer Lda, Porto Salvo, Portugal.
authors.forename: Mónica
authors.initials: M
authors.lastname: Inês
authors.affiliation: Centro de Estudos de Medicina Baseada na Evidência, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal.
authors.forename: Catarina
authors.initials: C
authors.lastname: Lopes Pereira
authors.affiliation: Serviço de Medicina 2, Centro Hospitalar Lisboa Norte EPE, Lisboa, Portugal.
authors.forename: Luís
authors.initials: L
authors.lastname: Pinheiro
authors.affiliation: Centro de Estudos de Medicina Baseada na Evidência, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal.
authors.forename: António
authors.initials: A
authors.lastname: Vaz-Carneiro
authors.affiliation: Centro de Estudos de Medicina Baseada na Evidência, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal; Laboratório de Farmacologia Clínica e Terapêutica, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal; Unidade de Farmacologia Clínica, Centro Hospitalar de Lisboa Central EPE, Lisboa, Portugal.
authors.forename: Margarida
authors.initials: M
authors.lastname: Borges
authors.affiliation: Católica Lisbon School of Business and Economics, Universidade Católica Portuguesa, Lisboa, Portugal.
authors.forename: Miguel
authors.initials: M
authors.lastname: Gouveia
mesh_terms: D000925:Anticoagulants / Q000627:therapeutic use*; D001281:Atrial Fibrillation / Q000188:drug therapy*; D001562:Benzimidazoles / Q000191:economics / Q000627:therapeutic use; D003362:Cost-Benefit Analysis; D000069604:Dabigatran / Q000191:economics / Q000627:therapeutic use; D006801:Humans; D011174:Portugal; D011720:Pyrazoles / Q000191:economics / Q000627:therapeutic use; D011728:Pyridones / Q000191:economics / Q000627:therapeutic use; D020521:Stroke / Q000188:drug therapy; D014859:Warfarin / Q000627:therapeutic use
chemical_list: D000925:Anticoagulants; D001562:Benzimidazoles; D011720:Pyrazoles; D011728:Pyridones; C522181:apixaban; D014859:Warfarin; D000069604:Dabigatran
keywords: Anos de vida ajustados pela qualidade; Anticoagulantes orais; Atrial fibrillation; Cost‐effectiveness; Custo‐efetividade; Fibrilhação auricular; Oral anticoagulants; Quality‐adjusted life years