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Cancer. 2020 Jan 30. doi: 10.1002/cncr.32724. [Epub ahead of print]

Cost-effectiveness analysis of low-dose direct oral anticoagulant (DOAC) for the prevention of cancer-associated thrombosis in the United States.

Author information

1
Division of Hematology, University of Washington School of Medicine, Seattle, Washington.
2
The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, University of Washington School of Pharmacy, Seattle, Washington.
3
Advanced Cancer Research Group and Department of Medicine, University of Washington, Seattle, Washington.
4
Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan.
5
Pharmacy Services, University of Washington Medical Center, Seattle, Washington.
6
Department of Hematology and Medical Oncology, Taussig Cancer Institute and Case Comprehensive Cancer Center, Cleveland Clinic, Cleveland, Ohio.
7
Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada.
8
Division of Medical Oncology, University of Washington School of Medicine, Seattle, Washington.
9
Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington.

Abstract

BACKGROUND:

Randomized controlled trials (RCTs) have demonstrated that low-dose direct oral anticoagulants (DOACs), including rivaroxaban and apixaban, may help reduce the incidence of cancer-associated venous thromboembolism (VTE).

METHODS:

A cost-utility analysis was performed from the health sector perspective using a Markov state-transition model in patients with cancer who are at intermediate-to-high risk for VTE. Transition probability, relative risk, cost, and utility inputs were obtained from a meta-analysis of the RCTs and relevant epidemiology studies. Differences in cost, quality-adjusted life-years (QALYs), and the incremental cost-effectiveness ratio (ICER) per patient were calculated over a lifetime horizon. One-way, probabilistic, and scenario sensitivity analyses were conducted.

RESULTS:

In patients with cancer at intermediate-to-high risk for VTE, treatment with low-dose DOAC thromboprophylaxis for 6 months, compared with placebo, was associated with 32 per 1000 fewer VTE and 11 per 1000 more major bleeding episodes over a lifetime. The incremental cost and QALY increases were $1445 and 0.12, respectively, with an ICER of $11,947 per QALY gained. Key drivers of ICER variations included the relative risks of VTE and bleeding as well as drug cost. This strategy was 94% cost effective at the threshold of $50,000 per QALY. The selection of patients with Khorana scores ≥3 yielded the greatest value, with an ICER of $5794 per QALY gained.

CONCLUSIONS:

Low-dose DOAC thromboprophylaxis for 6 months appears to be cost-effective in patients with cancer who are at intermediate-to-high risk for VTE. The implementation of this strategy in patients with Khorana scores ≥3 may lead to the highest cost-benefit ratio.

KEYWORDS:

apixaban; cost-benefit analysis; factor Xa inhibitors; neoplasm; rivaroxaban; venous thromboembolism

PMID:
31999844
DOI:
10.1002/cncr.32724

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