title: Cost Effectiveness of Apixaban versus Warfarin or Aspirin for Stroke Prevention in Patients with Atrial Fibrillation: A Greek Perspective.
abstract: BACKGROUND
  Strokes attributed to atrial fibrillation (AF) represent a major cause of adult disability and a great burden to society and healthcare systems.
  
  
  OBJECTIVE
  Our objective was to assess the cost effectiveness of apixaban, a direct acting oral anticoagulant (DOAC), versus warfarin or aspirin for patients with AF in the Greek healthcare setting.
  
  
  METHODS
  We used a previously published Markov model to simulate clinical events for patients with AF treated with apixaban, the vitamin K antagonist (VKA) warfarin, or aspirin. Clinical events (ischemic and hemorrhagic stroke, intracranial hemorrhage, other major bleed, clinically relevant non-major bleed, myocardial infarction, and cardiovascular [CV] hospitalizations) were modeled using efficacy data from the ARISTOTLE and AVERROES clinical trials. The cohort's baseline characteristics also sourced from these trials. Among VKA-suitable patients, 64.7% were men with a mean age of 70 years and average CHADS2(cardiac failure, hypertension, age, diabetes, stroke2) score of 2.1, whereas 58.5% of VKA-unsuitable patients were men with a mean age of 70 years and a CHADS2score of 2.0. A panel of experts (cardiologists and internists) provided information on the resource use associated with the management of AF. Cost calculations reflect the local clinical setting and a third-party payer perspective (€, discounted at 3%).
  
  
  RESULTS
  Based on a simulation of 1000 VKA-suitable patients over a lifetime horizon, the use of apixaban versus warfarin resulted in 26 fewer strokes and systemic embolisms in total, 65 fewer bleeds, 41 fewer myocardial infarctions, and 29 fewer CV-related deaths, with an incremental cost-effectiveness ratio (ICER) of €14,478/quality-adjusted life-year (QALY). For VKA-unsuitable patients, apixaban versus aspirin resulted in 72 fewer strokes and systemic embolisms and 57 fewer CV-related deaths, with an ICER of €7104/QALY. Sensitivity analyses indicated that results were robust.
  
  
  CONCLUSIONS
  Based on the present analysis, apixaban represents a cost-effective treatment option versus warfarin and aspirin for the prevention of stroke in patients with AF from a Greek healthcare payer perspective over a lifetime horizon.
authors.affiliation: Department of Health Economics, National School of Public Health, 196 Alexandras Avenue, 11521, Athens, Greece.
authors.forename: Kostas
authors.initials: K
authors.lastname: Athanasakis
authors.affiliation: Department of Health Economics, National School of Public Health, 196 Alexandras Avenue, 11521, Athens, Greece. nadia.phar@gmail.com.
authors.forename: Nadia
authors.initials: N
authors.lastname: Boubouchairopoulou
authors.affiliation: Department of Health Economics, National School of Public Health, 196 Alexandras Avenue, 11521, Athens, Greece.
authors.forename: Eleftheria
authors.initials: E
authors.lastname: Karampli
authors.affiliation: Department of Health Economics, National School of Public Health, 196 Alexandras Avenue, 11521, Athens, Greece.
authors.forename: Filippos
authors.initials: F
authors.lastname: Tarantilis
authors.affiliation: Pfizer Hellas, 243 Mesoghion Avenue, Athens, Greece.
authors.forename: Paraskevi
authors.initials: P
authors.lastname: Savvari
authors.affiliation: Pfizer Hellas, 243 Mesoghion Avenue, Athens, Greece.
authors.forename: Aikaterini
authors.initials: A
authors.lastname: Bilitou
authors.affiliation: Department of Health Economics, National School of Public Health, 196 Alexandras Avenue, 11521, Athens, Greece.
authors.forename: John
authors.initials: J
authors.lastname: Kyriopoulos
mesh_terms: D000925:Anticoagulants / Q000191:economics* / Q000627:therapeutic use*; D001241:Aspirin / Q000191:economics* / Q000627:therapeutic use*; D001281:Atrial Fibrillation / Q000150:complications* / Q000188:drug therapy* / Q000453:epidemiology; D003198:Computer Simulation; D003362:Cost-Benefit Analysis; D016527:Drug Costs; D005260:Female; D006115:Greece / Q000453:epidemiology; D006801:Humans; D008297:Male; D008962:Models, Theoretical; D010975:Platelet Aggregation Inhibitors / Q000191:economics* / Q000627:therapeutic use*; D011720:Pyrazoles / Q000191:economics* / Q000627:therapeutic use*; D011728:Pyridones / Q000191:economics* / Q000627:therapeutic use*; D012306:Risk; D020521:Stroke / Q000453:epidemiology* / Q000517:prevention & control*; D014859:Warfarin / Q000191:economics* / Q000627:therapeutic use*
chemical_list: D000925:Anticoagulants; D010975:Platelet Aggregation Inhibitors; D011720:Pyrazoles; D011728:Pyridones; C522181:apixaban; D014859:Warfarin; D001241:Aspirin