Cost-effectiveness analysis of different anticoagulant classes in cancer associated thrombosis (CAT) : a differential approach accounting thrombotic and bleeding risk, applied in the Greek health care environment

Abstract

Background: Guidelines recommend that Cancer-associated thrombosis (CAT) should be treated with low-molecular weight heparins (LMWH), which prevent more effectively the recurrence of Venous Thrombo-Embolism (VTE) than Vitamin K Antagonists (VKA). New Direct Oral Anti-coagulants (DOAC) may be more convenient and have been recently tested against LMWH in CAT patients. Objective: Assess the cost effectiveness of the different anticoagulant classes in CAT in the Greek Healthcare (HC) setting from the hospital perspective, accounting different bleeding/thrombotic Risk groups (High/Low) defined by presence of chemotherapy/metastasis. Methods: Markov chain modeling accounting VTE, Major Bleeding (MB), clinically relevant non-major bleeding (CRB) and death as major states, incorporating additional mortality risk by VTE and MB. All comparisons were made versus (vs) VKA as base. All costs were derived in the context of the Greek HC system and included direct pharmacological costs, Diagnosis Related Group (DRG) costs for the management of VTE, MB, CRB and secondary support costs of VKA (laboratory testing and HC professionals consultation visits). Results: For Low Risk CAT patients DOAC were more cost effective in all analyzed endpoints (VTE, MB, CRB) including Life Years Gained (LYG) and total Utility with a favorable estimated Incremental Cost-Effectiveness Ratio (ICER) of less than €300 per LYG or per Quality Adjusted Life Year (QALY) gained vs VKA. In High Risk CAT patients DOACs were dominated by VKA in QALY, LYG, MB and CRB with negative ICER values, making LMWH acceptably cost effective option (ICER of €15.000 per LYG and €22.000 per QALY gained vs DOAC). Conclusions: Risk stratification for CAT patients might prove useful achieving higher cost effectiveness from the different anticoagulant classes. For the Greek HC environment, DOAC seem more cost effective for the Low Risk CAT patients, while LMWH deem preferred for High Risk CAT patients offering acceptable cost-utility gains.