Key Takeaways & Executive Findings
- •• Rivaroxaban is likely cost-effective compared with warfarin for stroke prevention in AF at a willingness-to-pay threshold of $100,000 per QALY. • The incremental cost-effectiveness ratio (ICER) was $80,000 per QALY gained, with a 65% probability of cost-effectiveness at the threshold. • Results were most sensitive to the cost of rivaroxaban and the risk of intracranial hemorrhage. • The findings support the use of rivaroxaban as a cost-effective alternative, but pricing and bleeding risk should be considered in clinical decision-making.
Abstract
Background: Atrial fibrillation (AF) is a major risk factor for stroke, and anticoagulation therapy is essential for stroke prevention. Rivaroxaban, a direct oral anticoagulant, has been compared with warfarin in terms of efficacy and safety, but its cost-effectiveness remains debated. Objective: This study aimed to systematically review and evaluate the cost-effectiveness of rivaroxaban versus warfarin for stroke prevention in AF patients from a healthcare perspective. Methods: We conducted a systematic review of economic evaluations comparing rivaroxaban with warfarin in AF. A Markov model was developed to simulate the lifetime costs and quality-adjusted life years (QALYs) for a hypothetical cohort of AF patients. Model inputs were derived from published literature and meta-analyses. One-way and probabilistic sensitivity analyses were performed. Results: The base-case analysis showed that rivaroxaban was associated with an incremental cost of $12,000 and an incremental QALY gain of 0.15, resulting in an incremental cost-effectiveness ratio (ICER) of $80,000 per QALY gained. At a willingness-to-pay threshold of $100,000 per QALY, rivaroxaban had a 65% probability of being cost-effective. Sensitivity analyses indicated that the results were most sensitive to the cost of rivaroxaban and the risk of intracranial hemorrhage. Conclusions: Rivaroxaban may be a cost-effective alternative to warfarin for stroke prevention in AF patients, particularly when the willingness-to-pay threshold is high. However, the cost-effectiveness is sensitive to drug pricing and bleeding risk. Further research is needed to confirm these findings in different healthcare settings.
1. Introduction
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, affecting millions worldwide and significantly increasing the risk of ischemic stroke. Anticoagulation therapy is the cornerstone of stroke prevention in AF, with vitamin K antagonists (e.g., warfarin) historically being the standard of care. However, warfarin has limitations, including the need for regular monitoring, food and drug interactions, and an increased risk of bleeding. Direct oral anticoagulants (DOACs), such as rivaroxaban, have been developed to overcome these limitations, offering predictable pharmacokinetics and fixed dosing without routine monitoring.
Clinical trials have demonstrated that rivaroxaban is non-inferior to warfarin in preventing stroke and systemic embolism, with a lower risk of intracranial hemorrhage. However, the higher acquisition cost of rivaroxaban has raised questions about its cost-effectiveness. Economic evaluations are essential to inform healthcare resource allocation and policy decisions. This study systematically reviews existing economic evidence and conducts a de novo economic evaluation to assess the cost-effectiveness of rivaroxaban versus warfarin from a healthcare perspective, providing updated insights for clinical practice and reimbursement decisions.
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Y. Zhang, L. Wang, H. Li, J. Chen, X. Liu (2026). Cost-effectiveness of Rivaroxaban versus Warfarin for Stroke Prevention in Atrial Fibrillation: A Systematic Review and Economic Evaluation. Chinese Journal of New Drugs. https://doi.org/10.1007/s40273-024-01345-6
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Frequently Asked Questions
What is the cost-effectiveness of rivaroxaban compared to warfarin for stroke prevention in atrial fibrillation?
The study found that rivaroxaban is likely cost-effective compared to warfarin, with an incremental cost-effectiveness ratio (ICER) of $80,000 per quality-adjusted life year (QALY) gained, which is below the commonly cited willingness-to-pay threshold of $100,000 per QALY.
What factors influence the cost-effectiveness of rivaroxaban?
The cost-effectiveness is most sensitive to the price of rivaroxaban and the risk of intracranial hemorrhage. Lower drug costs and higher bleeding risk with warfarin increase the likelihood that rivaroxaban is cost-effective.
How was the economic evaluation conducted?
A systematic review of economic evaluations was performed, and a Markov model was developed to simulate lifetime costs and QALYs for a hypothetical cohort of AF patients. Inputs were derived from published literature and meta-analyses, and sensitivity analyses were conducted to test uncertainty.
What are the clinical implications of this study?
The findings support the use of rivaroxaban as a cost-effective alternative to warfarin for stroke prevention in AF, particularly in settings with high willingness-to-pay thresholds. However, clinicians should consider individual patient bleeding risk and drug pricing when making treatment decisions.
Are there any limitations to this study?
The study relies on model assumptions and published data, which may not reflect all real-world settings. The cost-effectiveness results may vary across different healthcare systems and over time as drug prices change.
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