Should Hemodialysis Patients With Atrial Fibrillation Undergo Systemic Anticoagulation? A Cost-Utility Analysis
Received 19 December 2006; accepted 23 May 2007. published online 10 August 2007.
Refers to article:
Anticoagulation for Chronic Atrial Fibrillation in Hemodialysis Patients: Which Fruit From the Decision Tree?
Kevin C. Abbott, Robert T. Neff, Erin M. Bohen, Rajeev Narayan
American Journal of Kidney Diseases
September 2007 (Vol. 50, Issue 3, Pages 345-348) Full Text |
Full-Text PDF (82 KB)
Background
Approximately 14% of hemodialysis patients have atrial fibrillation. Hemodialysis patients with atrial fibrillation appear to be at increased risk of both thromboembolic complications and bleeding. Furthermore, there is uncertainty regarding the efficacy of warfarin or acetylsalicylic acid (ASA) therapy for preventing strokes in this subgroup because they were excluded from relevant trials.
Study Design
We performed a cost-utility analysis. Probabilistic sensitivity analysis was used to incorporate parameter uncertainty into the model. Expected value of perfect information and scenario analyses were performed to identify the important drivers of the decision and focus future research.
Setting & Population
Base case was a 60-year-old male hemodialysis patient in the United States.
Model, Perspective, & Time Frame
A Markov Monte Carlo microsimulation model was constructed from the perspective of the health care payer, and patients were followed up during their lifetime.
Intervention
We compared 3 alternative treatment strategies for permanent atrial fibrillation in hemodialysis patients: warfarin, ASA, or no treatment.
Outcomes
Quality-adjusted survival and cost.
Results
ASA and warfarin both prolonged survival compared with no treatment (0.06 and 0.15 quality-adjusted life-years [QALYs], respectively). ASA was associated with an incremental cost-effectiveness ratio of $82,100/QALY. Warfarin provided additional benefits at a cost of $88,400 for each QALY gained relative to ASA. At a threshold of $100,000/QALY, the probabilities that no treatment, warfarin, and ASA were the most efficient therapy were 20%, 58%, and 23%, respectively.
Limitations
Parameterization data and costs were taken from US studies and may not be generalizable to other countries. Peritoneal dialysis patients were not included in the analysis.
Conclusions
The high future cost of hemodialysis constrains incremental cost-effectiveness ratios to values greater than commonly cited thresholds ($50,000/QALY). Based on available evidence, warfarin appears to be the optimal therapy to prevent thromboembolic stroke in hemodialysis patients with atrial fibrillation. Additional study is required to determine the efficacy of warfarin and risk of bleeding complications in this population so that patients can make a more informed choice.
1Department of Medicine, Division of Nephrology, Sunnybrook Health Sciences Centre, Toronto, Canada
2Medicine and Health Policy Management and Evaluation, University of Toronto, Toronto, Canada
3Chronic Dialysis, Sunnybrook Health Sciences Centre, Toronto, Canada
4Centre for Research on Inner City Health, The Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael’s Hospital, University of Toronto, Toronto, Canada.
Address correspondence to Robert R. Quinn, MD, FRCPC, Division of Nephrology, Department of Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Rm A239, Toronto, Ontario, Canada M4N 3M5.
ABSTRACT