Cost-effectiveness of apixaban vs aspirin for the reduction of thrombo-embolism in high-risk patients with device-detected atrial fibrillation: insights from the ARTESiA trial
Bibliographic record
Abstract
Abstract Background The Apixaban for the Reduction of Thrombo-Embolism in Patients with Subclinical Atrial Fibrillation (ARTESiA) trial demonstrated that apixaban, compared to aspirin, prevented stroke or systemic embolism, with the largest effect among patients with a CHA₂DS₂-VASc score >4. We hypothesize that apixaban in patients with a CHA₂DS₂-VASc score >4 will be cost-effective due to cost savings from stroke prevention. Methods Using healthcare perspectives specific to Canada, the UK, Germany and the US, direct healthcare costs (in 2023 USD) were applied to hospitalized events and study drugs used by all CHA₂DS₂-VASc score >4 participants. The daily cost of apixaban was $0.63, $0.11, $2.26, and $6.06 for Canada, the UK, Germany and the US. We determined the mean cost per participant for the full duration of the trial (mean follow-up of 3.5 years). If in-trial results were not cost-saving (below $0), we performed a lifetime cost-effectiveness analysis using a Markov model and assumed a willingness to pay of 50,000 USD per Quality Adjust Life-Year (QALY). The Markov model consisted of five states (Alive, Dead, Discontinued, Rankin 0-2 Post-Stroke and Rankin 3-5 Post-Stroke) with a 3-month cycle length. While alive, participants experienced one of eight events (no event, non-fatal myocardial infarction, non-fatal ischemic stroke, fatal ischemic stroke, non-fatal hemorrhagic stroke, fatal hemorrhagic stroke, major gastrointestinal/ genitourinary bleed, or death) based on data from the ARTESiA trial. Costs and utilities were obtained from national tariffs and published literature. Results During the trial, the cost of events was lower in the apixaban arm in all countries. After taking into consideration the cost of study medication, apixaban was cost saving (dominant strategy) in Canada (-$2301) and the UK (-$902) but cost more in Germany and the US ($600 and $1990 respectively) and thus modelling was required for these two countries. Over a lifetime, apixaban results in 4.995 QALYs compared to 4.888 QALYs for patients taking aspirin; a difference of 0.107 QALYs. During this period participants taking apixaban accrued higher costs than those taking aspirin in both Germany ($2623 more) and the US ($9110 more). This resulted in an incremental cost effectiveness ratio of $24,514 for Germany and $85,140 per QALY for the US. One-way sensitivity analyses of drug and event costs and of event probabilities used in our model identified the cost of apixaban as the only factor impacting cost-effectiveness. In the US, this sensitivity analysis indicates a daily cost of $4.35 is required to achieve a willingness-to-pay of $50,000/QALY. Conclusion In patients with device detected atrial fibrillation with CHA₂DS₂-VASc score >4, apixaban is cost-saving in Canada and the UK and cost-effective in Germany. Apixaban is not cost-effective in the US at current prices.Table 1
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.008 | 0.017 |
| Meta-epidemiology (narrow) | 0.001 | 0.000 |
| Meta-epidemiology (broad) | 0.002 | 0.006 |
| Bibliometrics | 0.000 | 0.001 |
| Science and technology studies | 0.000 | 0.000 |
| Scholarly communication | 0.002 | 0.001 |
| Open science | 0.001 | 0.001 |
| Research integrity | 0.001 | 0.002 |
| Insufficient payload (model declined to judge) | 0.004 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".