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Cost-effectiveness of Dabigatran and Rivaroxaban Compared with Warfarin for Stroke Prevention in Patients with Atrial Fibrillation

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Abstract

Purpose

This study aimed to evaluate the cost-effectiveness of dabigatran and rivaroxaban compared with warfarin for the prevention of stroke in patients with atrial fibrillation (AF) in Singapore.

Methods

A Markov model was constructed to compare the lifetime costs, quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios (ICERs) of dabigatran 110 and 150 mg, rivaroxaban 20 mg and adjusted-dose warfarin from the perspective of the Singapore healthcare system, using clinical data from published studies, utilities from a patient-reported survey and costs from hospital databases. The target population was a hypothetical cohort of 65-year-old AF patients with no contraindications to anticoagulation.

Results

In the base-case analysis, the QALYs were 8.75 with warfarin, 8.73 with dabigatran 110 mg, 8.82 with dabigatran 150 mg, and 9.33 with rivaroxaban. The costs were Singapore dollar (SG$) 34,648 for warfarin, SG$54,919 for dabigatran 110 mg, SG$50,484 for dabigatran 150 mg and SG$51,975 for rivaroxaban. The ICER of rivaroxaban versus warfarin was SG$29,697 (US$26,727) per QALY. Rivaroxaban and warfarin had extended dominance over the high-dose dabigatran. The low-dose dabigatran was dominated by warfarin. Deterministic sensitivity analyses showed that the ICER of rivaroxaban versus warfarin was sensitive to cost of rivaroxaban and utilities for rivaroxaban and warfarin. Probability sensitivity analysis demonstrated that the probability of rivaroxaban being the optimal choice was 97.8 % and 99.5 % at a willingness-to-pay threshold of SG$65,000 (US$58,500) and SG$130,000 (US$117,000) per QALY, respectively.

Conclusion

Rivaroxaban may be a cost-effective alternative to warfarin for the prevention of stroke in patients with AF in Singapore.

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Acknowledgments

We would like to acknowledge the National University of Singapore for providing us with a research grant.

Conflict of Interest

The authors declare that they have no conflict of interest.

Author information

Authors and Affiliations

  1. Center for Surgery and Public Health, Brigham and Women’s Hospital, Harvard Medical School, One Brigham Circle, 1620 Tremont Street, 4-020, Boston, MA, 02120, USA

    Ye Wang

  2. Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Canada

    Feng Xie

  3. Department of Pharmacy, Singapore General Hospital, Outram Park, Singapore

    Ming Chai Kong

  4. Department of Hematology, Singapore General Hospital, Outram Park, Singapore

    Lai Heng Lee & Heng Joo Ng

  5. Department of Pharmacy, Faculty of Science, National University of Singapore, Level 3, Block S4A, 18 Science Drive 4, Singapore, 117543, Singapore

    Yu Ko

Authors
  1. Ye Wang
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  2. Feng Xie
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  3. Ming Chai Kong
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  4. Lai Heng Lee
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  5. Heng Joo Ng
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Corresponding authors

Correspondence to Ye Wang or Yu Ko.

Appendix

Appendix

Part 1

Descriptions of health states

Descriptions of health states (available upon request) were developed based on preference assessment guidelines, medical textbooks, published literature and expert opinions (i.e., two researchers with Ph.D. degrees in pharmacy, two physicians with master’s degrees in medicine, a clinical pharmacist with a master’s degree in pharmacy and a Ph.D. candidate in pharmacy). Important attributes of the health states were described. Examples are shown below.

Well on warfarin

You need to take an oral medicine once daily with occasional dose adjustments. You need to attend the outpatient clinic at a hospital or polyclinic about once a month for a blood test. You are not able to drink too much alcohol. You may bruise more easily, but generally you are in your good health state.

Well on dabigatran

You need to take an oral medicine twice daily with a fixed dose. You may have dyspepsia (i.e., stomach discomfort or burning pain), but generally you are in your good health state.

Well on rivaroxaban

You need to take an oral medicine once daily with a fixed dose. Generally you are in your good health state.

Part 2

Table 3 Parameterization of distributions for the probabilistic sensitivity analysis
Full size table

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Wang, Y., Xie, F., Kong, M.C. et al. Cost-effectiveness of Dabigatran and Rivaroxaban Compared with Warfarin for Stroke Prevention in Patients with Atrial Fibrillation. Cardiovasc Drugs Ther 28, 575–585 (2014). https://doi.org/10.1007/s10557-014-6558-1

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  • DOI: https://doi.org/10.1007/s10557-014-6558-1

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