title: [Comparison of the cost-utility of direct oral anticoagulants for the prevention of stroke in patients with atrial fibrillation in Spain].
abstract: BACKGROUND
  Apixaban, dabigatran and rivaroxaban are three new direct oral anticoagulants (DOACs) used in the prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation (NVAF) in Spain.
  
  
  OBJECTIVE
  To assess the relative cost-utility of the three DOACs compared with vitamin K antagonists.
  
  
  METHODS
  A Markov model with 3-month cycles was used to simulate NVAF patients starting with treatment and followed up for their lifetime from the perspective of the National Health System. The model included 36 health states including treatment combinations, disability and events history and considered a hypothetical cohort of 10,000 NVAF patients. Relative efficacy was calculated from a formal indirect treatment comparison using data from the pivotal trials of each DOAC.
  
  
  RESULTS
  Dabigatran was associated with the highest number of quality-adjusted life years (QALY) (8.40 QALY), followed by apixaban (8.33 QALY), rivaroxaban (8.15 QALY) and acenocoumarol (8.03 QALY). Patients taking acenocoumarol had the lowest total costs (€22,230), followed by dabigatran (€24,564), apixaban (€24,655) and rivaroxaban (€25,900). Incremental cost-utility ratios compared to vitamin K antagonists, were €6,397, €8,039 and €29,957/QALY for dabigatran, apixaban and rivaroxaban, respectively. If compared together, dabigatran dominated apixaban and rivaroxaban. Sensitivity analyses confirmed the robustness of the baseline case.
  
  
  CONCLUSIONS
  All three direct anticoagulants are cost-effective against acenocoumarol. Dabigatran is economically dominant over rivaroxaban and apixaban in the Spanish setting, as it is more effective and cheaper.
authors.affiliation: Hospital Universitari Germans Trias i Pujol, 08916 Badalona, Espana.
authors.forename: M
authors.initials: M
authors.lastname: Monreal-Bosch
authors.affiliation: Boehringer Ingelheim Espana, Sant Cugat del Valles, Espana.
authors.forename: S
authors.initials: S
authors.lastname: Soulard
authors.affiliation: Boehringer Ingelheim Espana, Sant Cugat del Valles, Espana.
authors.forename: C
authors.initials: C
authors.lastname: Crespo
authors.affiliation: Evidera, Londres, Reino Unido.
authors.forename: S
authors.initials: S
authors.lastname: Brand
authors.affiliation: Evidera, Bethesda, MD, EE.UU.
authors.forename: A
authors.initials: A
authors.lastname: Kansal
mesh_terms: D000284:Administration, Oral; D000368:Aged; D000925:Anticoagulants / Q000008:administration & dosage* / Q000191:economics*; D001281:Atrial Fibrillation / Q000150:complications; D003362:Cost-Benefit Analysis; D000069604:Dabigatran / Q000008:administration & dosage* / Q000191:economics*; D005260:Female; D006801:Humans; D008297:Male; D008390:Markov Chains; D011720:Pyrazoles / Q000008:administration & dosage* / Q000191:economics*; D011728:Pyridones / Q000008:administration & dosage* / Q000191:economics*; D000069552:Rivaroxaban / Q000008:administration & dosage* / Q000191:economics*; D013030:Spain; D020521:Stroke / Q000191:economics* / Q000209:etiology / Q000517:prevention & control*; D014812:Vitamin K / Q000037:antagonists & inhibitors*
chemical_list: D000925:Anticoagulants; D011720:Pyrazoles; D011728:Pyridones; D014812:Vitamin K; C522181:apixaban; D000069552:Rivaroxaban; D000069604:Dabigatran