Korean Circ J.  2019 Mar;49(3):252-263. 10.4070/kcj.2018.0220.

Cost-Effectiveness of Rivaroxaban Compared to Warfarin for Stroke Prevention in Atrial Fibrillation

• Kim H
• Kim H
• Cho SK
• Kim JB
• Joung B
• Kim C

• KMID: 2438536
• DOI: http://doi.org/10.4070/kcj.2018.0220

Abstract

BACKGROUND AND OBJECTIVES
Rivaroxaban is 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 (ICH). We assessed the cost-effectiveness of rivaroxaban compared to adjusted-dose warfarin for the prevention of stroke in patients with nonvalvular AF.
METHODS
We built a Markov model using the Korean Health Insurance Review & Assessment Service database. The base-case analysis assumed a cohort of patients with prevalent AF who were aged 18 years or older without contraindications to anticoagulation.
RESULTS
Number of patients with CHA2DS2-VASc scores 0, 1 and ≥2 were 56 (0.2%), 1,944 (6.3%) and 28,650 (93.5%), respectively. In patients with CHA2DS2-VASc scores ≥2, the incidence rate of ischemic stroke was 3.11% and 3.76% in warfarin and rivaroxaban groups, respectively. The incidence rates of ICH were 0.42% and 0.15%, and those of gastrointestinal bleeding were 0.32% and 0.15% in warfarin and rivaroxaban, respectively. Patients with AF treated with rivaroxaban lived an average of 11.8 quality-adjusted life years (QALYs) at a lifetime treatment cost of $20,886. Those receiving warfarin lived an average of 11.4 QALYs and incurred costs of $17,151. Patients with rivaroxaban gained an additional 0.4 QALYs over a lifetime with an additional cost of $3,735, resulting in an incremental cost-effectiveness ratio of $9,707 per QALY.
CONCLUSIONS
Patients who had been treated with rivaroxaban may be a cost-effective alternative to warfarin for stroke prevention in Korean patients with AF.

Keyword

Atrial fibrillation; Rivaroxaban; Warfarin; Cost effectiveness

MeSH Terms

Atrial Fibrillation*
Cohort Studies
Cost-Benefit Analysis
Embolism
Health Care Costs
Hemorrhage
Humans
Incidence
Insurance, Health
Intracranial Hemorrhages
Quality-Adjusted Life Years
Rivaroxaban*
Stroke*
Warfarin*
Rivaroxaban
Warfarin

Figure

• 

  Figure 1 Schematic representation of Markov model shows that all patients start at 65 years of age with AF and then cycle between health states until death occurs or the 20-year time horizon is reached. Probabilities of these events depend on prescribed therapies. The length of each cycle is 1 year. Patients can die from stroke, hemorrhage, MI, or other co-morbidities. Decision node (square), chance nodes (circles) under the control of transition probabilities, and terminal nodes (triangles) are depicted.AF = atrial fibrillation; ECH = extracranial hemorrhage; M = Markov node; MI = myocardial infarction; RIND = reversible ischemic neurological deficit.

• 

  Figure 2 Cost-effectiveness scatterplot.QALY = quality-adjusted life-year.

• 

  Figure 3 Changes in ICER estimates for rivaroxaban compared to warfarin with different time horizons. Employing a shorter time horizon (e.g., 1 year) results in a peak ICER of $9,707 perQALY. Vertical dotted line demarcates the $9,707 per QALY threshold.ICER = incremental cost-effectiveness ratio; QALY = quality-adjusted life-year.

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