Cost-effectiveness of direct oral anticoagulants compared to low-molecular-weight-heparins for treatment of cancer associated venous thromboembolism in Spain

Figures & data

Figure 1. Model structure. For each simulated cancer patient, the different VTE treatment states are represented by ellipses and each transition between two states is represented by an arrow between those states.

Table 1. Probabilities.

	LMWH	Apixaban	Edoxaban	Rivaroxaban	References
Venous thrombosis embolism	Based on clinical trial^7^,^9^,^22^,^23
Pulmonary embolism (% VTE)
0–6 months	55%	58%	68%	50%	^7^,^9^,^22^,^23
7–12 months	31%	57%	57%	57%	^7
Chronic thromboembolic Pulmonary hypertension	0.9%	0.9%	0.9%	0.9%	^26
Post-thrombotic syndrome after DVT	6.7%	6.7%	6.7%	6.7%	^27
Major bleeding	Based on clinical trial^7^,^9^,^22^,^23
Non-intracranial major bleeding (% mb)
0–6 months	87.5%	100%	93.1%	100%	^7^,^9^,^22^,^23
7–12 months	100%	100%	100%	100%	^7
Clinically relevant non-major bleeding (%)
0–6 months	6.4%	8.5%	12.3%	12.3%	^7^,^9^,^22^,^23
7–12 months	3.8%	3.1%	3.1%	3.1%	^7

DVT: deep vein thrombosis; LMWH: low molecular weight heparin; MB: major bleeding; VTE: venous thrombosis embolism.

Table 2. Utilities table.

	Utilities	References
Baseline*	0.6925	^19^,^29
	Disutility
Pulmonary embolism	0.253	^19^,^30^,^31
Deep vein thrombosis	0.15	^19^,^30^,^31
Recurring VTE	0.075	^19
Clinically relevant non-major bleeding	0.0565	^19^,^32
Major bleeding (MB)	0.164	^19^,^31^,^32
Intracranial bleeding, 1st month	0.5195	^32
Intracranial bleeding, 2nd month	0.2725	^32
Intracranial bleeding, 3rd month and after	0.2125	^32
Post-thrombotic syndrome	0.05	^33
Chronic thromboembolic pulmonary hypertension	0.34	^34

Table 3. Pharmacological cost for short and long term.

Active ingredient	Monthly cost short term	Monthly cost long term
LMWH	216.22€	194.38€
Bemiparin	234.61€	234.61€
Dalteparin	190.30€	142.73€
Enoxaparin	203.72€	152.79€
Nadroparin	137.18€	137.18€
Tinzaparin	206.09€	206.09€
DOAC	106.96€	75.19€
Apixaban	103.66€	84.05€
Edoxaban*	103.18€	80.57€
Rivaroxaban	142.87€	84.04€

DOAC: direct oral anticoagulant; LMWH: low molecular weight heparin.

*Includes the cost of low molecular weight heparin.

Table 4. Costs and effectiveness for each treatment after 12 months.

Comparator 12 months	Cost	Life years	ICER (€/LY)	QALYs	ICER (€/QALYs)
LMWH	2,1512€	0.76		0.53
DOAC	1,994€	0.77		0.54
Apixaban	1,944€	0.79		0.55
Rivaroxaban	2,122€	0.76		0.53
Edoxaban	1,968€	0.74		0.52
Difference vs. LMWH
DOAC	−518.09€	0.01	Dominant	0.01	Dominant
Apixaban	−568.56€	0.03	Dominant	0.02	Dominant
Rivaroxaban	−390.66€	−0.00	130,757€/LY	−0.00	247,375€/QALY
Edoxaban	−544.57€	−0.02	22,972€/LY	−0.02	33,963€/QALY
Difference vs. apixaban
DOAC	50.48€	−0.02	Dominated	−0.01	Dominated
Rivaroxaban	177.91€	−0.03	Dominated	−0.02	Dominated
Edoxaban	24.00€	−0.05	Dominated	−0.04	Dominated

DOAC: direct oral anticoagulant; ICER: incremental cost-effectiveness ratio; LF: life years; LMWH: low molecular weight heparin; QALY: quality-adjusted life year.

Figure 2. Tornado diagram based on Net Monetary Benefit. The 10 most sensitive factors that account for most of the variability in the model. DOAC: direct oral anticoagulants compared; LMWH: low-molecular-weight-heparins.

Figure 3. Cost-effectiveness plane of DOAC vs. LMWH. It represents the 1000 simulations run by the model and the 95% confidence ellipse that comprises most of them. DOAC: direct oral anticoagulants compared; LMWH: low-molecular-weight-heparins.

Figure 4. Acceptability curves for the LMWH and DOAC. DOAC: direct oral anticoagulants compared; LMWH: low-molecular-weight-heparins.

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