A Decision Analysis of Percutaneous Left Atrial Appendage Occlusion Relative to Novel and Traditional Oral Anticoagulation for Stroke Prevention in Patients with New-Onset Atrial Fibrillation.

Autor:	Micieli A; Faculty of Medicine, University of Ottawa, Ontario, Canada (AM), Wijeysundera HC; Schulich Heart Centre, Sunnybrook Health Sciences Centre, Faculty of Medicine, University of Toronto, Ontario, Canada (HCW, SMS); Institute of Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada (HCW); Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada (HCW, FQ, CLA), Qiu F; Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada (HCW, FQ, CLA), Atzema CL; Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada (HCW, FQ, CLA); Division of Emergency Medicine, Faculty of Medicine, University of Toronto, Ontario, Canada (CLA)., Singh SM; Faculty of Medicine, University of Ottawa, Ontario, Canada (AM); Schulich Heart Centre, Sunnybrook Health Sciences Centre, Faculty of Medicine, University of Toronto, Ontario, Canada (HCW, SMS)
Jazyk:	angličtina
Zdroj:	Medical decision making : an international journal of the Society for Medical Decision Making [Med Decis Making] 2016 Apr; Vol. 36 (3), pp. 366-74. Date of Electronic Publication: 2015 Jul 02.
DOI:	10.1177/0272989X15593083
Abstrakt:	Background: Percutaneous left atrial appendage occlusion (LAAO) is a nonpharmacologic approach for stroke prevention in nonvalvular atrial fibrillation (NVAF). No direct comparisons to novel oral anticoagulants (OACs) exists, limiting decision making on the optimal strategy for stroke prevention in NVAF patients. Addressing this gap in knowledge is timely given the recent debate by the US Food and Drug Administration regarding the effectiveness of LAAO. Objective: To assess the cost-effectiveness of LAAO and novel OACs relative to warfarin in patients with new-onset NVAF without contraindications to OAC. Design: A cost-utility analysis using a patient-level Markov micro-simulation decision analytic model was undertaken to determine the lifetime costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio (ICER) of LAAO and all novel OACs relative to warfarin. Effectiveness and utility data were obtained from the published literature and cost from the Ontario Drug Benefits Formulary and Case Costing Initiative. Results: Warfarin had the lowest discounted QALY (5.13 QALYs), followed by dabigatran (5.18 QALYs), rivaroxaban and LAAO (5.21 QALYs), and apixaban (5.25 QALYs). The average discounted lifetime costs were $15 776 for warfarin, $18 280 for rivaroxaban, $19 156 for apixaban, $20 794 for dabigatran, and $21 789 for LAAO. Apixaban dominated dabigatran and LAAO and demonstrated extended dominance over rivaroxaban. The ICER for apixaban relative to warfarin was $28 167/QALY. Apixaban was preferred in 40.2% of simulations at a willingness-to-pay threshold of $50 000/QALY. Limitations: Assumptions regarding clinical and methodological differences between published studies of each therapy were minimized. Conclusions: Apixaban is the most cost-effective therapy for stroke prevention in patients with new-onset NVAF without contraindications to OAC. Uncertainty around this conclusion exists, highlighting the need for further research. (© The Author(s) 2015.)
Databáze:	MEDLINE
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