Cost-effectiveness Of Left Atrial Appendage Closure,New Oral Anticoagulants And Warfarin In Preventing Stroke In Patients With Atrial Fibrillation

Objective:Based on the current domestic economic and medical situation,the cost-effectiveness analysis of different treatment strategies such as dose adjusted warfarin,new oral anticoagulant(NOAC)and left atrial appendage closure(LAAC)to prevent stroke risk in patients with non valvular atrial fibrillation(NVAF,hereinafter referred to as atrial fibrillation)was compared.It will provide reference and help for the formulation of medical security policy,the decision-making of clinical treatment plan and the rational allocation of medical resources in China in the future.Methods:This study adopts a retrospective research method,from the perspective of the whole society,based on the clinical trial data of rock AF,RE-LY,PROTECT AF and so on,uses Treeage Pro2011 to construct a Markov model to simulate the cost-effectiveness analysis of patients’ 30-year survival cycle under each treatment strategy,and evaluates the economic benefits of three treatment strategies to compare the stroke risk of warfarin in patients with atrial fibrillation in the 30-year life cycle,Sensitivity analysis and probability analysis are carried out to determine the factors that have a great impact on this study and verify the stability of the model.Results:The results show that after 30 cycles of the model cycle,the total cost and total effect of the LAAC group are 123,000 yuan and 9.34 QALY;The total cost and total effect of Rivaroxaban group are 154,000 yuan and 9.15 QALY;The total cost and total effect of Dabigatran group(110mg)are 187,000 yuan and 9.72 QALY;The total cost and total effect of Dabigatran group(150mg)are 222,000 yuan and 9.92 QALY.Compared to warfarin group,the incremental cost-effectiveness ratio(ICER)of LAAC group is 172,000 yuan/QALY,which is lower than the current willingness to pay value(WTP=240,000 yuan).In the predicted30-year life cycle,LAAC is more economical for warfarin.After further calculation,in the 18 th year,LAAC group began to possess economic benefits compared with warfarin group.With the extension of life cycle,the economic advantages of LAAC group will be more obvious.Compared to warfarin group,the incremental cost-effectiveness ratio(ICER)of rivaroxaban group is 238,000 yuan/QALY,which is lower than the current willingness to pay value(WTP=240,000 yuan).In the predicted30-year life cycle,rivaroxaban possesses economic benefits compared with warfarin.Compared to warfarin group,the incremental cost-effectiveness ratio(ICER)of dabigatran(110mg)and dabigatran(150mg)groups are 612,000yuan/QALY and 414,000 yuan/QALY respectively.Lower than the current willingness to pay value(WTP=240,000 yuan).In the predicted 30-year life cycle,different doses of dabigatran have no economic benefits compared with warfarin.The results of univariate sensitivity analysis showed that the most significant factor between LAAC and warfarin group is the health utility value after myocardial infarction(e＿p＿MB);Between rivaroxaban and warfarin group,the most significant factor is the death transfer probability of warfarin group(p＿DIE＿W);Between different doses of dabigatran and warfarin group,the most significant factor is the death transfer probability of warfarin group(p＿DIE＿W);However,in the study,the health utility value after myocardial infarction and the death transfer probability of warfarin group don’t have a significant impact on the incremental cost-effectiveness ratio(ICER).Therefore,the model is relatively stable.Probability sensitivity analysis shows that the treatment cost and effect of LAAC,rivaroxaban and different doses of dabigatran are higher than warfarin group.When WTP=240,000 yuan/QALY(three times GDP in 2021),the probability of acceptance of LAAC,rivaroxaban,dabigatran(110mg)and dabigatran(150mg)are 67%,57%,6% and 7% respectively.Basically consistent with the cost utility analysis,the Markov model is robust and reliable.Conclusion:At the current economic level,Different doses of dabigatran are not economically beneficial compared to dose-adjusted warfarin for stroke prevention in patients with atrial fibrillation,whereas rivaroxaban and left atrial appendage closure are more economically beneficial than warfarin.