RESEARCH – December 2016

The cost-effectiveness of new oral anticoagulants in Estonia

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Aim. To evaluate the cost-effectiveness and budget impact of new oral anticoagulants in patients with non-valvular atrial fibrillation in Estonia. This review is based on the health technology assessment carried out by the Department of Public Health, University of Tartu.

Methods. A Markov cohort model was used to compare the standard warfarin and no treatment scenarios to the new oral anticoagulants – dabigatran and rivaroxaban – in a hypothetical cohort of 65-year-old patients with atrial fibrillation. Data for disease transition probabilities and quality of life outcomes for diferent treatments was obtained from published literature with treatment costs calculated based on the 2010–2012 Estonian Health Insurance Fund data and drug retail prices. The analysis evaluated different treatment regimens for avoided complications and differences in costs and quality-adjusted life-years (QALYs) using incremental costeffectiveness ratios ( ICER). Budget impact analysis evaluated drug and treatment costs for 2014–2018 compared to the baseline data from 2013.

Results. In the base-case scenario, ICER for dabigatran (150 mg twice per day and 110 mg twice per day from age 80) was €20,696 per QALY and €30,215 for rivaroxaban, respectively, compared to warfarin treatment. Compared to warfarin, QALY the gains for new oral anticoagulants were 0.23–0.37 per patient. Compared to no treatment, the new anticoagulants add 1.05–1.20 QALYs with an ICER of €7,734–7,970, being influenced the most by a change in the time perspective, discount rate and reduction in medication costs in sensitivity analysis. When ideal treatment adherence and full coverage of the target group is assumed, the overall costs for anticoagulation therapy are likely to increase 1.16–2.17 times from 2014 to 2018, compared to baseline in 2013, with additional annual costs being € 5.1 M.

Conclusions. The improved efficiency of the new oral anticoagulants dabigatran and rivaroxaban comes would result from higher costs. Although the cost-effectiveness ratio according to our analysis is comparable to results from previously published sources, the wider use of the new oral anticoagulants would increase the overall costs for the Estonian Health Insurance Fund significantly, surpassing the costs of avoided complications. This rapid increase is due to the higher drug costs of dabigatran and rivaroxaban, compared to warfarin, rise in discount rate and high population coverage owing to better access to anticoagulation therapy.