Cost-effectiveness of left atrial appendage closure with the WATCHMAN device compared with warfarin or non-Vitamin K antagonist oral anticoagulants for secondary prevention in nonvalvular atrial fibrillation

Vivek Y. Reddy, Ronald L. Akehurst, Stacey L. Amorosi, Meghan B. Gavaghan, Deanna S. Hertz, David Holmes

Research output: Contribution to journalArticle

6 Citations (Scopus)

Abstract

Background and Purpose-Once a patient with atrial fibrillation experiences an embolic event, the risk of a recurrent event increases 2.6-fold. New treatments have emerged as viable treatment alternatives to warfarin for stroke risk reduction in secondary prevention populations. This analysis sought to assess the cost-effectiveness of left atrial appendage closure (LAAC) compared with warfarin and the non-Vitamin K antagonist oral anticoagulants dabigatran 150 mg, apixaban and rivaroxaban in the prevention of stroke in nonvalvular atrial fibrillation patients with a prior stroke or transient ischemic attack. Methods-A Markov model was constructed using data from the secondary prevention subgroup analyses of the non- Vitamin K antagonist oral anticoagulant and LAAC pivotal trials. Costs were from 2016 US Medicare reimbursement rates and the literature. The cost-effectiveness analysis was conducted from a US Medicare perspective over a lifetime (20 years) horizon. The model was populated with a cohort of 10 000 patients aged 70 years with a CHA2DS2-VASc score of 7 (annual stroke risk=9.60%) and HAS-BLED score of 3 (annual bleeding risk=3.74%). Results-LAAC achieved cost-effectiveness relative to dabigatran at year 5 and warfarin and apixaban at year 6. At 10 years, LAAC had more quality-adjusted life years (4.986 versus 4.769, 4.869, 4.888, and 4.810) and lower costs ($42 616 versus $53 770, $58 774, $55 656, and $58 655) than warfarin, dabigatran, apixaban, and rivaroxaban, respectively, making LAAC the dominant (more effective and less costly) stroke risk reduction strategy. LAAC remained the dominant strategy over the lifetime analysis. Conclusions-Upfront procedure costs initially make LAAC higher cost than warfarin and the non-Vitamin K antagonist oral anticoagulants, but within 10 years, LAAC delivers more quality-adjusted life years and has lower total costs, making LAAC the most cost-effective treatment strategy for secondary prevention of stroke in atrial fibrillation.

Original languageEnglish (US)
Pages (from-to)1464-1470
Number of pages7
JournalStroke
Volume49
Issue number6
DOIs
StatePublished - Jan 1 2018

Fingerprint

Atrial Appendage
Warfarin
Secondary Prevention
Anticoagulants
Atrial Fibrillation
Cost-Benefit Analysis
Equipment and Supplies
Stroke
Costs and Cost Analysis
Quality-Adjusted Life Years
Risk Reduction Behavior
Medicare
Vitamin K
Transient Ischemic Attack
Health Care Costs
Hemorrhage

Keywords

  • apixaban
  • atrial fibrillation
  • cost-effectiveness analysis
  • dabigatran
  • left atrial appendage closure
  • warfarin

ASJC Scopus subject areas

  • Clinical Neurology
  • Cardiology and Cardiovascular Medicine
  • Advanced and Specialized Nursing

Cite this

Cost-effectiveness of left atrial appendage closure with the WATCHMAN device compared with warfarin or non-Vitamin K antagonist oral anticoagulants for secondary prevention in nonvalvular atrial fibrillation. / Reddy, Vivek Y.; Akehurst, Ronald L.; Amorosi, Stacey L.; Gavaghan, Meghan B.; Hertz, Deanna S.; Holmes, David.

In: Stroke, Vol. 49, No. 6, 01.01.2018, p. 1464-1470.

Research output: Contribution to journalArticle

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abstract = "Background and Purpose-Once a patient with atrial fibrillation experiences an embolic event, the risk of a recurrent event increases 2.6-fold. New treatments have emerged as viable treatment alternatives to warfarin for stroke risk reduction in secondary prevention populations. This analysis sought to assess the cost-effectiveness of left atrial appendage closure (LAAC) compared with warfarin and the non-Vitamin K antagonist oral anticoagulants dabigatran 150 mg, apixaban and rivaroxaban in the prevention of stroke in nonvalvular atrial fibrillation patients with a prior stroke or transient ischemic attack. Methods-A Markov model was constructed using data from the secondary prevention subgroup analyses of the non- Vitamin K antagonist oral anticoagulant and LAAC pivotal trials. Costs were from 2016 US Medicare reimbursement rates and the literature. The cost-effectiveness analysis was conducted from a US Medicare perspective over a lifetime (20 years) horizon. The model was populated with a cohort of 10 000 patients aged 70 years with a CHA2DS2-VASc score of 7 (annual stroke risk=9.60{\%}) and HAS-BLED score of 3 (annual bleeding risk=3.74{\%}). Results-LAAC achieved cost-effectiveness relative to dabigatran at year 5 and warfarin and apixaban at year 6. At 10 years, LAAC had more quality-adjusted life years (4.986 versus 4.769, 4.869, 4.888, and 4.810) and lower costs ($42 616 versus $53 770, $58 774, $55 656, and $58 655) than warfarin, dabigatran, apixaban, and rivaroxaban, respectively, making LAAC the dominant (more effective and less costly) stroke risk reduction strategy. LAAC remained the dominant strategy over the lifetime analysis. Conclusions-Upfront procedure costs initially make LAAC higher cost than warfarin and the non-Vitamin K antagonist oral anticoagulants, but within 10 years, LAAC delivers more quality-adjusted life years and has lower total costs, making LAAC the most cost-effective treatment strategy for secondary prevention of stroke in atrial fibrillation.",
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AU - Akehurst, Ronald L.

AU - Amorosi, Stacey L.

AU - Gavaghan, Meghan B.

AU - Hertz, Deanna S.

AU - Holmes, David

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N2 - Background and Purpose-Once a patient with atrial fibrillation experiences an embolic event, the risk of a recurrent event increases 2.6-fold. New treatments have emerged as viable treatment alternatives to warfarin for stroke risk reduction in secondary prevention populations. This analysis sought to assess the cost-effectiveness of left atrial appendage closure (LAAC) compared with warfarin and the non-Vitamin K antagonist oral anticoagulants dabigatran 150 mg, apixaban and rivaroxaban in the prevention of stroke in nonvalvular atrial fibrillation patients with a prior stroke or transient ischemic attack. Methods-A Markov model was constructed using data from the secondary prevention subgroup analyses of the non- Vitamin K antagonist oral anticoagulant and LAAC pivotal trials. Costs were from 2016 US Medicare reimbursement rates and the literature. The cost-effectiveness analysis was conducted from a US Medicare perspective over a lifetime (20 years) horizon. The model was populated with a cohort of 10 000 patients aged 70 years with a CHA2DS2-VASc score of 7 (annual stroke risk=9.60%) and HAS-BLED score of 3 (annual bleeding risk=3.74%). Results-LAAC achieved cost-effectiveness relative to dabigatran at year 5 and warfarin and apixaban at year 6. At 10 years, LAAC had more quality-adjusted life years (4.986 versus 4.769, 4.869, 4.888, and 4.810) and lower costs ($42 616 versus $53 770, $58 774, $55 656, and $58 655) than warfarin, dabigatran, apixaban, and rivaroxaban, respectively, making LAAC the dominant (more effective and less costly) stroke risk reduction strategy. LAAC remained the dominant strategy over the lifetime analysis. Conclusions-Upfront procedure costs initially make LAAC higher cost than warfarin and the non-Vitamin K antagonist oral anticoagulants, but within 10 years, LAAC delivers more quality-adjusted life years and has lower total costs, making LAAC the most cost-effective treatment strategy for secondary prevention of stroke in atrial fibrillation.

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