From the Division of General Medical Sciences, Washington University, St
Louis, Mo (B.F.G.); Veterans Affairs Palo Alto Health Care System (Calif)
(A.B.C., D.K.O.); and Division of General Internal Medicine and Department of
Health Research and Policy, Stanford University (Calif) (D.K.O.).
Correspondence to Brian F. Gage, MD, MSc, Washington University School of Medicine, General Medical Sciences, Campus Box 8005, 660 S Euclid Ave, St Louis, MO 63110. E-mail gage{at}osler.wustl.edu
Background and Purpose—Recent atrial
fibrillation guidelines recommend the incorporation of patient
preferences into the selection of antithrombotic therapy. However, no
trial has examined how incorporating such preferences would affect
quality-adjusted survival or medical expenditure. We compared 10-year
projections of quality-adjusted survival and medical expenditure
associated with two atrial fibrillation treatment strategies:
warfarin-for-all therapy versus preference-based therapy. The
preference-based strategy prescribed whichever antithrombotic therapy,
warfarin or aspirin, had the greater projected
quality-adjusted survival.
Methods—We used decision analysis stratified by the
number of stroke risk factors (history of stroke, transient
ischemic attack, hypertension, diabetes, or heart disease). The
base case focused on compliant 65-year-old patients who had
nonvalvular atrial fibrillation and no contraindications to
antithrombotic therapy.
Results—In patients whose only risk factor for stroke was atrial
fibrillation, preference-based therapy improved projected
quality-adjusted survival by 0.05 quality-adjusted life year (QALY) and
saved $670. For patients who had atrial fibrillation and one additional
risk factor for stroke, preference-based therapy improved
quality-adjusted survival by 0.02 QALY and saved $90. In patients who
had atrial fibrillation and multiple additional risk factors for
stroke, preference-based therapy increased medical expenditures and did
not improve quality-adjusted survival substantially. The benefits of
preference-flexible therapy arose from the minority of patients who
would have had a longer quality-adjusted survival if they had been
prescribed aspirin rather than warfarin.
Conclusions—As do risks of stroke and of hemorrhage,
patients' preferences help to determine which antithrombotic therapy
is optimal. Preference-based treatment should improve quality-adjusted
survival and reduce medical expenditure in patients who have
nonvalvular atrial fibrillation and not more than one
additional risk factor for stroke.
© 1998 American Heart Association, Inc.
Original Contributions
Cost-Effectiveness of Preference-Based Antithrombotic Therapy for Patients With Nonvalvular Atrial Fibrillation
Key Words: aspirin • atrial fibrillation • costs and cost analysis • stroke prevention • warfarin
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