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

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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.
Funding Information
  • Cleveland Clinic (Sondra and Stephen Hardis Chair in Oncology Resear)
  • Hemostasis and Thrombosis Research Society (Mentored Research Award)
  • Conquer Cancer Foundation (Young Investigator Award)
  • National Hemophilia Foundation (Clinical Fellowship Award)
  • University of Ottawa (T2 Research Chair in Venous Thromboembolism and Ca)
  • National Heart, Lung, and Blood Institute (U01‐HL143402)

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