Economic evaluation of the use of non-vitamin K oral anticoagulants in patients with atrial fibrillation on anti-platelet therapy: A modelling analysis using the healthcare system in the Netherlands.

Aims: Non-vitamin K oral anticoagulants (NOACs) have consistently demonstrated superior efficacy in terms of stroke prevention and safety in terms of bleeding over vitamin K antagonist (VKA) in patients with non-valvular atrial fibrillation (AF). The potential use of NOACs in AF patients requiring anti-platelet therapy has only been assessed in small meta-analyses reporting consistent benefits of NOACs over VKAs. However, the prescription costs of NOACs are higher than those of VKAs. The aim of his study was to estimate the cost-effectiveness of NOACs compared to VKAs in patients with non-valvular AF also requiring anti-platelet therapy with the Dutch healthcare system used as a surrogate of many European healthcare systems.

Methods and Results: A decision tree was constructed to analyse the cost-effectiveness of NOACs compared to VKAs in patients with non-valvular AF with an indication for anti-platelet therapy over a horizon of 1 year. Beside the base case analysis, univariate probabilistic sensitivity and two sensitivity analyses were performed: first, we assessed the impact of VKA home monitoring; second, we varied the NOACs price assuming patent expiration. Use of NOACs instead of VKA is associated with a health gain of 0.0171 QALYs and with an incremental cost of €357, resulting in an ICER of €20.919, which is almost equal to the generally accepted cost-effectiveness threshold of €20.000 used in the Netherlands. The probability that NOACs are cost-effective at a conservative willingness-to pay threshold of €20,000 per QALY was 50%. Introducing home monitoring increased VKAs costs so much that NOACs became the dominant option (less costly and more effective). Price drops associated to patent expiration of NOACs increased its cost-effectiveness.

Conclusion: This analysis suggests that the use of NOACs is a cost-effective alternative of VKAs in patients with AF needing anti-platelet therapy. Our findings in the Netherlands healthcare system are probably consistent with other European populations.