Patients on vitamin K treatment: is switching to direct-acting oral anticoagulation cost-effective? A target trial on a prospective cohort.

Autor:	Aebersold H; Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland helena.aebersold@uzh.ch., Foster-Witassek F; Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland., Aeschbacher S; Cardiology Division, Department of Medicine, University Hospital Basel, Basel, Switzerland.; Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland., Beer JH; Department of Medicine, Cantonal Hospital of Baden, Baden, Switzerland.; Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland., Blozik E; Institute of Primary Care, University of Zurich, Zurich, Switzerland., Blum M; Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland.; Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland., Bonati L; Department of Neurology, University Hospital Basel, Basel, Switzerland.; Research Department, Reha Rheinfelden, Rheinfelden, Switzerland., Conte G; Division of Cardiology, Cardiocentro Ticino (CCT), Lugano, Switzerland., Coslovsky M; Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland.; Clinical Trial Unit Basel, Department of Clinical Research, University Hospital Basel, Basel, Switzerland., De Perna ML; Division of Cardiology, Istituto Cardiocentro Ticino, Ospedale Regionale di Bellinzona, Bellinzona, Switzerland., Di Valentino M; Division of Cardiology, Istituto Cardiocentro Ticino, Ospedale Regionale di Bellinzona, Bellinzona, Switzerland., Felder S; Faculty of Business and Economics, University of Basel, Basel, Switzerland., Huber CA; Department of Health Sciences, Helsana Group, Zurich, Switzerland., Moschovitis G; Division of Cardiology, Ente Ospedaliero Cantonale (EOC), Istituto Cardiocentro Ticino, Ospedale Regionale di Lugano, Lugano, Switzerland., Mueller A; Department of Cardiology, Triemli Hospital Zurich, Zurich, Switzerland., Paladini RE; Cardiology Division, Department of Medicine, University Hospital Basel, Basel, Switzerland.; Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland., Reichlin T; Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland., Rodondi N; Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland.; Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland., Stauber A; Department of Cardiology, Triemli Hospital Zurich, Zurich, Switzerland., Sticherling C; Cardiology Division, Department of Medicine, University Hospital Basel, Basel, Switzerland.; Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland., Szucs TD; Health Economics Facility, Department of Public Health, University of Basel, Basel, Switzerland., Conen D; Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada., Kuhne M; Cardiology Division, Department of Medicine, University Hospital Basel, Basel, Switzerland.; Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland., Osswald S; Cardiology Division, Department of Medicine, University Hospital Basel, Basel, Switzerland.; Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland., Schwenkglenks M; Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland.; Health Economics Facility, Department of Public Health, University of Basel, Basel, Switzerland., Serra-Burriel M; Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland.
Jazyk:	angličtina
Zdroj:	Open heart [Open Heart] 2024 Jan 31; Vol. 11 (1). Date of Electronic Publication: 2024 Jan 31.
DOI:	10.1136/openhrt-2023-002567
Abstrakt:	Aims: Direct-acting oral anticoagulants (DOACs) have, to a substantial degree, replaced vitamin K antagonists (VKA) as treatments for stroke prevention in atrial fibrillation (AF) patients. However, evidence on the real-world causal effects of switching patients from VKA to DOAC is lacking. We aimed to assess the empirical incremental cost-effectiveness of switching patients to DOAC compared with maintaining VKA treatment. Methods: The target trial approach was applied to the prospective observational Swiss-AF cohort, which enrolled 2415 AF patients from 2014 to 2017. Clinical data, healthcare resource utilisation and EQ-5D-based utilities representing quality of life were collected in yearly follow-ups. Health insurance claims were available for 1024 patients (42.4%). Overall survival, quality-of-life, costs from the Swiss statutory health insurance perspective and cost-effectiveness were estimated by emulating a target trial in which patients were randomly assigned to switch to DOAC or maintain VKA treatment. Results: 228 patients switching from VKA to DOAC compared with 563 patients maintaining VKA treatment had no overall survival advantage over a 5-year observation period (HR 0.99, 95% CI 0.45, 1.55). The estimated gain in quality-adjusted life years (QALYs) was 0.003 over the 5-year period at an incremental costs of CHF 23 033 (€ 20 940). The estimated incremental cost-effectiveness ratio was CHF 425 852 (€ 387 138) per QALY gained. Conclusions: Applying a causal inference method to real-world data, we could not demonstrate switching to DOACs to be cost-effective for AF patients with at least 1 year of VKA treatment. Our estimates align with results from a previous randomised trial. Competing Interests: Competing interests: JHB reports grant support from the Swiss National Foundation of Science, The Swiss Heart Foundation and the Stiftung Kardio; grant support, speakers and consultation fees to the institution from Bayer, Sanofi and Daichii Sankyo. EB reports grants from Swiss Cancer Research Foundation, Amgen, MSD, Novartis, Vifor, all outside the submitted work. MB is supported by grants from the Swiss National Science Foundation and the Swiss Heart Foundation. LB reports personal fees and non-financial support from Amgen, grants from AstraZeneca, personal fees and non-financial support from Bayer, personal fees from Bristol-Myers Squibb, personal fees from Claret Medical, grants from Swiss National Science Foundation, grants from University of Basel, grants from Swiss Heart Foundation, outside the submitted work. DC received consulting fees from Roche Diagnostics, and speaker fees from Servier and BMS/Pfizer, all outside of the current work. MK reports grants from Bayer, grants from Pfizer, grants from Boston Scientific, grants from BMS, grants from Biotronik, grants and personal fees from Daiichi Sankyo. GM has received advisory board and/or speaker’s fees from Astra Zeneca, Bayer, Boehringer Ingelheim, Daiichi Sankyo, Gebro Pharma, Novartis and Vifor, all outside of the submitted study. AM reports fellowship and training support from Biotronik, Boston Scientific, Medtronic, Abbott/St. Jude Medical and Biosense Webster; speaker honoraria from Biosense Webster, Medtronic, Abbott/St Jude Medical, AstraZeneca, Daiichi Sankyo, Biotronik, MicroPort, Novartis, and consultant honoraria for Biosense Webster, Medtronic, Abbott/St. Jude Medcal and Biotronik. SO received research grants from the Swiss National Science Foundation and from the Swiss Heart Foundation, research grants from Foundation for CardioVascular Research Basel, research grants from Roche, educational and speaker office grants from Roche, Bayer, Novartis, Sanofi AstraZeneca, Daiichi-Sankyo and Pfizer. TR has received research grants from the Swiss National Science Foundation, the Swiss Heart Foundation, and the sitem insel support fund, all for work outside the submitted study. Speaker/consulting honoraria or travel support from Abbott/SJM, Astra Zeneca, Brahms, Bayer, Biosense-Webster, Biotronik, Boston-Scientific, Daiichi Sankyo, Medtronic, Pfizer-BMS and Roche, all for work outside the submitted study. Support for his institution’s fellowship programme from Abbott/SJM, Biosense-Webster, Biotronik, Boston-Scientific and Medtronic for work outside the submitted study. MS reports grants from Swiss National Science Foundation, for the conduct of the study; grants from Amgen, grants from MSD, grants from Novartis, grants from Pfizer, grants from Roche, grants and personal fees from BMS and personal fees from Sandoz, all outside the submitted work. MS-B reports grants from the European Commission outside of the present work. CS has received speaker honoraria from Biosense Webster and Medtronic and research grants from Biosense Webster, Daiichi-Sankyo and Medtronic. The remaining authors have nothing to disclose. (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)
Databáze:	MEDLINE
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