Arrhythmias and conduction disturbances
Cost–Effectiveness of Rivaroxaban Compared to Warfarin for Stroke Prevention in Atrial Fibrillation

https://doi.org/10.1016/j.amjcard.2012.05.011Get rights and content

Rivaroxaban has been found to be noninferior to warfarin for preventing stroke or systemic embolism in patients with high-risk atrial fibrillation (AF) and is associated with a lower rate of intracranial hemorrhage. To assess the cost–effectiveness of rivaroxaban compared to adjusted-dose warfarin for the prevention of stroke in patients with AF, we built a Markov model using a United States payer/Medicare perspective and a lifetime time horizon. The base-case analysis assumed a cohort of patients with AF 65 years of age with a congestive heart failure, hypertension, age, diabetes, stroke (2 points) score of 3 and no contraindications to anticoagulation. Data sources included the Rivaroxaban Once-daily Oral Direct Factor Xa Inhibition Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation (ROCKET-AF) and other studies of anticoagulation. Outcome measurements included costs in 2011 United States dollars, quality-adjusted life years (QALYs), and incremental cost–effectiveness ratios (ICERs). Patients with AF treated with rivaroxaban lived an average of 10.03 QALYs at a lifetime treatment cost of $94,456. Those receiving warfarin lived an average of 9.81 QALYs and incurred costs of $88,544. The ICER for rivaroxaban was $27,498 per QALY. These results were most sensitive to changes in the hazard decrease of intracranial hemorrhage and stroke with rivaroxaban, cost of rivaroxaban, and time horizon. Monte Carlo simulation demonstrated rivaroxaban was cost–effective in 80% and 91% of 10,000 iterations at willingness-to-pay thresholds of $50,000 and $100,000 per QALY, respectively. In conclusion, this Markov model suggests that rivaroxaban therapy may be a cost–effective alternative to adjusted-dose warfarin for stroke prevention in AF.

Section snippets

Methods

We developed a Markov cohort model to evaluate the cost–effectiveness of rivaroxaban 20 mg 1 times/day (15 mg/day in patients with creatinine clearances from 15 to 50 mL/min) compared to adjusted-dose warfarin in patients with AF (Figure 1). Base-case analysis consisted of a cohort of patients with AF 65 years old at high-risk for stroke (congestive heart failure, hypertension, age, diabetes, stroke [CHADS2] score of 3) and no contraindications to anticoagulation. Health states modeled included

Results

Under base-case assumptions, patients with AF treated with adjusted-dose warfarin lived an average of 9.812 QALYs, incurring average lifetime treatments costs of $88,544. Those treated with rivaroxaban lived an average of 10.027 QALYs, with an average lifetime cost of $94,456. Thus, the ICER for rivaroxaban was $27,498 per QALY.

At the lowest range of rivaroxaban drug cost, $123, rivaroxaban became an economically dominant strategy (Figure 2). Conversely, when using the highest range of

Discussion

Our Markov model demonstrates rivaroxaban may be a cost–effective alternative to warfarin in patients with AF regardless of baseline ischemic stroke risk. Patients on rivaroxaban gained an additional 0.215 QALYs over a lifetime but at an additional cost of $5,912, resulting in an ICER of $27,498 per QALY. The cost–effectiveness of rivaroxaban was found to be sensitive to HRs for stroke and ICH, cost of rivaroxaban, utility of being on the drug, monthly cost of ICH, and time horizon of the

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    Dr. Coleman has received research funding from Janssen Pharmaceuticals, Inc., and is a member of their speaker's bureau. Dr. Kluger is a member of Janssen Pharmaceuticals, Inc. (Titusville, New Jersey), speakers' bureau.

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