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Integrating Real-World Evidence in Economic Evaluation of Oral Anticoagulants for Stroke Prevention in Non-valvular Atrial Fibrillation in a Developing Country

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Abstract

Objective

This study aimed to estimate the cost effectiveness of non-vitamin K oral anticoagulants (NOACs) compared with warfarin for stroke prevention in patients with non-valvular atrial fibrillation (NVAF) in Thailand where suboptimal anticoagulation control is common.

Materials and Methods

A hypothetical cohort of 65-year-old patients with NVAF and their disease progression was simulated in the Markov model. The following anticoagulant agents were used: warfarin, dabigatran, rivaroxaban, and apixaban. Warfarin with high, intermediate, and low time in therapeutic ranges (TTR) was used as the three different reference treatments. Baseline clinical events were obtained from a recently published real-world study in Thailand. A lifetime horizon was utilized in this model, and all analyses were performed from societal and healthcare perspectives. The results were reported as incremental cost-effectiveness ratios (ICERs) in 2021 US dollars per quality-adjusted life-year (QALY) gained. The sensitivity analyses were performed to assess the influence of parameter uncertainty.

Results

Apixaban was a cost-effective intervention compared with warfarin with low and intermediate TTR groups. In the low TTR group, the ICERs were $779 and $816 per QALY gained from the societal and healthcare perspectives, respectively, and in the intermediate TTR group, the ICERs were $2038 and $3159 per QALY gained from the societal and healthcare perspectives, respectively. Both ICERs were below the accepted willingness-to-pay threshold ($4806) in the context of Thailand’s healthcare.

Conclusions

In a developing country where suboptimal anticoagulation control is common, apixaban was the cost-effective alternative to warfarin for patients with both low and intermediate TTR control.

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Author information

Authors and Affiliations

  1. Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, UT, USA

    M. Sakil Syeed, Teerawat Nonthasawadsri & Nathorn Chaiyakunapruk

  2. Division of Epidemiology, School of Medicine, University of Utah, Salt Lake City, UT, USA

    Richard E. Nelson

  3. Informatics, Decision Enhancement and Analytics Sciences (IDEAS) Center, Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, UT, USA

    Richard E. Nelson & Nathorn Chaiyakunapruk

  4. Clinical Pharmacy Division, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, 447 Sri-Ayutthaya Road, Ratchathewi, 10400, Bangkok, Thailand

    Surakit Nathisuwan

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  1. M. Sakil Syeed
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Correspondence to Surakit Nathisuwan.

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Funding

No sources of funding were used to assist in the preparation of this study.

Conflict of interest

M. Sakil Syeed, Teerawat Nonthasawadsri, Richard E. Nelson, Nathorn Chaiyakunapruk and Surakit Nathisuwan declare they have no potential conflicts of interest that might be relevant to the contents of this manuscript.

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Data availability statement

All data generated or analyzed during this study are included in this published article (and its supplementary information files).

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Author contributions

All authors have made substantial contributions to this study. All authors were involved in the conception and design of the study. SS, TN, and SN were responsible for acquisition of the data. All authors were responsible for data analysis and data interpretation, drafting of the manuscript, and approved the final version.

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Syeed, M.S., Nonthasawadsri, T., Nelson, R.E. et al. Integrating Real-World Evidence in Economic Evaluation of Oral Anticoagulants for Stroke Prevention in Non-valvular Atrial Fibrillation in a Developing Country. Am J Cardiovasc Drugs 23, 173–183 (2023). https://doi.org/10.1007/s40256-023-00570-z

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