Table 2.
Cost effectiveness of management strategies in high-income countries
| Author, year and reference | Price year, and currency | Study perspective | Class of atrial fibrillation | Base-case intervention | Comparator(s) | Willingness-to-pay threshold | ICER (as reported in original studies) | ICER in 2021 US dollars | Cost-effective strategy |
|---|---|---|---|---|---|---|---|---|---|
| Stroke prevention for low risk of stroke patients | |||||||||
| Kongnakorn et al., 2015 [30] | 2013, Euro | Payer | All classes | Warfarin | Apixaban; dabigatran; rivaroxaban | €30,000 | Apixaban 5mg: €7212/QALY | Apixaban 5 mg: 9960/QALY | Apixaban |
| Lee et al., 2016 [33] | 2014, USD | Provider | All classes | Warfarin |
Aspirin; clopidogrel + aspirin; LAAC; dabigatran; apixaban; rivaroxaban |
$50,000 | LAAC: $6298/QALY | LAAC: 7112/QALY | LAAC |
| Rognoni et al., 2014 [37] | 2013, Euro | Payer | All classes | Warfarin | Apixaban; dabigatran; rivaroxaban | €25,000 | Apixaban 5 mg: €9631/QALY | Apixaban 5 mg: 14,574/QALY | Apixaban |
| Verhoef et al., 2014 [40] | 2012, Euro | Provider | All classes | Coumarin derivative | Apixaban; dabigatran; rivaroxaban | €20,000 | The Netherlands, Apixaban: €13,024/QALY. UK, Dabigatran: €11,172/QALY. | The Netherlands. Apixaban: 18,422/QALY. UK. Dabigatran: 15,803/QALY |
Apixaban and Dabigatran |
| Verhoef et al., 2016 [41] | 2014, GBP, SEK | Provider | All classes | Std of care | Pharmacogenetic-guided warfarin | £20,000 (UK); 500,000 SEK (Sweden) | UK, £6702/QALY. Sweden, 253,848 SEK | UK, 10,885/QALY. Sweden, 33,040/QALY | Pharmacogenetic-guided warfarin |
| Wang et al., 2014 [43] | 2012, USD | Provider | Paroxysmal | Warfarin | Dabigatran; rivaroxaban | $58,500 | Rivaroxaban: $26,727/QALY | Rivaroxaban: 31,291/QALY | Rivaroxaban |
| Stroke prevention for moderate risk of stroke patients | |||||||||
| Athanasakis et al., 2015 [18] | 2013, Euro | Payer | All classes | Apixaban | Dabigatran; rivaroxaban | €30,000 | Apixaban: ≤ €13,727/QALY (relative to comparators) | Apixaban: ≤ 24,302/QALY (relative to comparators) | Apixaban |
| Canestaro et al., 2013 [19] | 2011, USD | Societal | All classes | Warfarin | Apixaban; dabigatran; rivaroxaban | $100,000 | Apixaban: $93,063/QALY | Apixaban: 111,043/QALY | Apixaban |
| Cervantes et al., 2022 [20] | 2018, Euro | Payer | All classes | Warfarin | Apixaban; dabigatran; rivaroxaban | €22,000 | Rivaroxaban: €952/QALY. | Rivaroxaban: 1560/QALY. | Rivaroxaban |
| Choi et al., 2022 [21] | 2020, USD | Provider | All classes | Warfarin | Apixaban; dabigatran; edoxaban; rivaroxaban | $32,000 | Apixaban: $8427/QALY. | Apixaban: 8602/QALY | Apixaban |
| Coyle et al., 2013 [22] | 2011, CAD | Payer | All classes | Warfarin | Apixaban; dabigatran; rivaroxaban | $50,000 |
Dabigatran 150 mg: $20,797/QALY; Apixaban: $24,312/QALY |
Dabigatran 150 mg: 19,975/QALY; Apixaban: 23,351/QALY |
Dabigatran 150 mg was optimal if the CHADS2 score was less than 2 or more than 2 with previous minor stroke |
| de Jong et al., 2019 [23] | 2018, Euro | Societal | All classes | Apixaban | Warfarin; dabigatran; edoxaban; rivaroxaban | €20,000 | Apixaban: €3506/QALY | Apixaban: 4665/QALY | Apixaban |
| Freeman et al., 2016 [24] | 2014, USD | Payer | All classes | LAAC | Dabigatran; warfarin | $50,000 | LAAC versus warfarin: $20,486/QALY. dabigatran: $23,422/QALY | LAAC versus warfarin: 23,133/QALY. dabigatran: 26,448/QALY | LAAC |
| Harrington et al., 2013 [25] | 2012, USD | Provider | All classes | Warfarin | Apixaban; dabigatran; rivaroxaban | $50,000 | Apixaban 5 mg: $15,026/QALY. | Apixaban 5 mg: 17,592/QALY. | Apixaban |
| Janzic and Kos, 2015 [27] | 2014, Euro | Payer | All classes | Warfarin | Apixaban; dabigatran; edoxaban; rivaroxaban | €25,000 | Genotype-guided warfarin dosing: $6959/QALY. | Genotype-guided warfarin dosing: 12,896/QALY | Pharmacogenetic-guided warfarin |
| Micieli et al., 2016 [34] | 2012, CAD | Payer | Paroxysmal | LAAC | Apixaban; dabigatran; warfarin; rivaroxaban | $50,000 | Apixaban: $28,167/QALY | Apixaban: 20,782/QALY | Apixaban |
| Pradelli et al., 2014 [35] | 2013, Euro | Payer | All classes | Apixaban | Dabigatran; rivaroxaban | €20,000 | Apixaban: €3882/QALY. | Apixaban: 5874/QALY. | Apixaban |
| Rognoni et al., 2014 [37] | 2013, Euro | All classes | Warfarin | Apixaban; dabigatran; rivaroxaban | €25,000 | Dabigatran: €7609/QALY | Dabigatran: 11,514/QALY | Dabigatran | |
| Shah et al., 2016 [8] | 2015, USD | Payer | All classes | Warfarin | Apixaban; dabigatran; edoxaban; rivaroxaban | $100,000 | Apixaban: $25,816/QALY | Apixaban: 28,843/QALY | Apixaban |
| Vargas et al., 2018 [39] | 2015, USD | Payer | All classes | Warfarin | Apixaban; dabigatran; edoxaban; rivaroxaban | $100,000 | Edoxaban: $86,882/QALY | Edoxaban: 97,068/QALY | Edoxaban |
| Walter et al., 2021 [42] | 2018, Euro | Provider | All classes | Apixaban | Warfarin; dabigatran; edoxaban; rivaroxaban | €28,000 | Apixaban: €12,743/QALY | Apixaban: 16,156/QALY | Apixaban |
| Wong et al., 2020 [44] | 2018, CAD | Payer | All classes | Aspirin |
Apixaban; dabigatran; edoxaban; rivaroxaban; warfarin |
$50,000 | Apixaban: $5517/QALY | Apixaban: 4848/QALY | Apixaban |
| Zhao et al., 2016 [47] | 2015, USD | Payer | All classes | Warfarin | Apixaban; dabigatran; edoxaban; rivaroxaban | $49,700 | Apixaban: $24,476/QALY | Apixaban: 27,348/QALY | Apixaban |
| Zheng et al., 2014 [48] | 2013, GBP | Payer | All classes | Dabigatran | Apixaban; warfarin; rivaroxaban | £25,000 | Dabigatran: dominates | Dabigatran: dominates | Dabigatran |
| Stroke prevention for patients at high risk of stroke | |||||||||
| Hospodar et al., 2018 [26] | 2015, USD | Payer | All classes | Warfarin | Apixaban; dabigatran; edoxaban; rivaroxaban | $100,000 | Warfarin: dominates | Warfarin: dominates | Warfarin (for patients who can achieve TTR of 70%) |
| Labori et al., 2022 [31] | 2020, Euro | Provider; societal | All classes | Std of care | LAAC | €45,829 |
LAAC: €4047/QALY (provider). Cost-saving (societal) |
LAAC: 466/QALY (provider). Cost-saving (societal) |
LAAC |
| Lanitis et al., 2014 [32] | 2012, Euro | Payer | All classes | Warfarin |
Apixaban; Aspirin; dabigatran; edoxaban; rivaroxaban |
€30,000 | Apixaban: €12,227/QALY | Apixaban: 17,077/QALY | Apixaban |
| Reddy et al., 2018 [36] | 2016, USD | Payer | All classes | LAAC | Warfarin; apixaban; dabigatran | $50,000 | LAAC: dominates | LAAC: dominates | LAAC |
| Rognoni et al., 2014 [37] | 2013, Euro | Payer | All classes | Warfarin | Apixaban; dabigatran; rivaroxaban | €25,000 | Apixaban: €4723/QALY | Apixaban: 7147/QALY | Apixaban |
| Saw et al., 2016 [38] | 2015, CAD | Payer | All classes | Aspirin (patients contraindicated for OACs) | LAAC | Not defined | LAAC: dominates | LAAC: dominates | LAAC |
| Wu et al., 2021 [45] | 2018, USD | Payer | All classes | Warfarin | Apixaban; dabigatran; edoxaban; rivaroxaban | $50,000 | Edoxaban: $15,864/QALY; | Edoxaban: 16,826/QALY | Edoxaban |
| You Joyce, 2015 [46] | 2015, USD | Payer | Paroxysmal | Genotype-guided DOAC | Universal use of DAOC | $50,000 | DOAC: $314,129/QALY | DOAC: 350,959/QALY | Pharmacogenomic-guided warfarin |
| Shah et al., 2016 [8] | 2015, USD | Payer | All classes | Warfarin | Apixaban; dabigatran; edoxaban; rivaroxaban | $100,000 | Dabigatran: $31,435/QALY | Dabigatran: 35,120/QALY | Dabigatran |
| Rate control for patients at low risk of stroke | |||||||||
| Kim et al., 2019 [10] | 2017, USD | Societal | All classes | Atenolol | Propranolol; betaxolol; bevantolol; bisoprolol; diltiazem; verapamil | $30,000 | Propranolol: cost saving | Propranolol: cost saving | Propranolol |
| Rhythm control for patients at low risk of stroke | |||||||||
| Khaykin et al., 2015 [56] | 2012, USD | Payer | Paroxysmal | AAD | CA | $50,000 |
Ablation: Lifetime: $1228/QALY. 10 year: $22,879/QALY. |
Ablation: Lifetime: 1 438/QALY. 10 year: 26,786/QALY. |
CA (for a lifetime or minimum of 10 years) |
| Anderson et al., 2014 [57] | 2013, USD | Payer | Persistent | AAD | Convergent procedure; CA | Not defined | CA: $30,596/QALY; Convergent: $20,640/QALY | CA: 35,202/QALY; Convergent: 23,748/QALY | Convergent procedure |
| Kim et al., 2019 [10] | 2017, USD | Societal | All classes | Atenolol | Sotalol; Pilsicainide Flecainide; Propafenone Dronedarone; Amiodarone | $30,000 | Sotalol: $227/QALY. | Sotalol: 246/QALY. | Sotalol |
| Pathak et al., 2017 [61] | 2010, AUD | Provider | Paroxysmal and persistent | No RFM | RFM | Not defined |
RFM: −$52,305/QALY (4 year). −$62,653/QALY (10 year) |
RFM: Cost saving (4 year). Cost saving (10 year) |
Risk factor management |
| Reynolds et al., 2014 [62] | 2011, GBP | Payer | Paroxysmal | AAD | Cryoballoon ablation | £30,000/QALY | Cryoballoon: £21,957/QALY | Cryoballoon: 37,525/QALY | Cryoballoon ablation |
| Rhythm control for patients at moderate risk of stroke | |||||||||
| Anderson et al., 2014 [57] | 2013, USD | Payer | Persistent | AAD | Convergent procedure; CA | Not defined | CA: $11,175/QALY. Convergent: $2214/QALY | CA: 12,857/QALY. Convergent: 2547/QALY | Convergent procedure |
| Lau et al., 2021 [59] | 2018, CAD | Payer | Paroxysmal and persistent | AAD | CA | $50,000 | CA: $35,360/QALY | CA: 31,071/QALY | CA |
| Rhythm control for patients at high risk of stroke | |||||||||
| Anderson et al., 2014 [57] | 2013, USD | Payer | Persistent | AAD | Convergent procedure; CA | Not defined | Convergent versus CA: dominant | Convergent: dominant | Convergent procedure |
| Chew et al., 2022 [58] | 2018, USD | Provider | Persistent | AAD | Catheter ablation | $100,000 | Catheter ablation: $57,893/QALY | Catheter ablation: 61,403/QALY | Catheter ablation |
| Leung et al., 2022 [60] | 2019, GBP | Payer | All classes | AAD | Catheter ablation | £20,000 | £8614/QALY | 12,869/QALY | Catheter ablation |
| Mixed treatment strategy: rhythm control and stroke prevention | |||||||||
| Kimura et al., 2017 [29] | 2014, Yen | Payer | Paroxysmal AF | CA + warfarin | CA + dabigatran | ¥6,000,000 |
CA + warfarin: ¥3.45–5.70 M/QALY. CA + dabigatran: ¥3.81M–8.08M/QALY |
CA + warfarin: 62,896/QALY. CA + dabigatran: 89,158/QALY |
CA + warfarin for low to moderate risk of stroke. CA + dabigatran for high risk of stroke |
| Kawakami et al., 2021 [28] | 2020, USD | Provider | All classes | CA + std OAC | CA + LAAC | $50,000/QALY | CA + LAAC strategy: $11,072/QALY | CA + LAAC strategy: 11,302/QALY | CA + LAAC |
AAD anti-arrhythmic drugs, AF atrial fibrillation, CA catheter ablation, LAAC left atrial appendage closure, OAC oral anti-coagulant, QALY quality-adjusted life-years, RFCA radiofrequency catheter ablation, RFM risk factor management, TTR time to therapeutic range, USD United States dollars, VKA vitamin K antagonist