The potential clinical and economic outcomes of pharmacogenetics-oriented management of warfarin therapy – a decision analysis

2004 ◽  
Vol 92 (09) ◽  
pp. 590-597 ◽  
Author(s):  
Fredric Chan ◽  
Raymond Wong ◽  
Gregory Cheng ◽  
Joyce You
Keyword(s):  
Cost Effectiveness ◽  
Major Bleeding ◽  
Marginal Cost ◽  
Warfarin Therapy ◽  
Anticoagulation Therapy ◽  
Economic Outcomes ◽  
Treatment Scheme ◽  
Increased Risk ◽  
The Cost ◽  
Anticoagulation Service

SummaryVariant cytochrome P450 (CYP) 2C9 genotypes are associated with low maintenance dose requirement of warfarin therapy and increased risk of major bleeding events. The objective of the present study was to evaluate the potential clinical and economic outcomes of using CYP2C9 genotype data to guide the management of anticoagulation therapy and to identify influential factors affecting the cost-effectiveness of this treatment scheme. A decision tree was designed to simulate, over 12 months, the clinical and economic outcomes of patients newly started on warfarin associated with two alternatives: (1) no genotyping (non-genotyped group) and (2) CYP2C9 genotyping prior to initiation of warfarin therapy (genotyped group). Nongenotyped group patients would receive standard care of an anticoagulation clinic (AC). In the genotyped group, patients with at least one variant CYP2C9 allele would receive intensified anticoagulation service. Most of the clinical probabilities were derived from literature. The direct medical costs were estimated from the Diagnosis-Related Group charges and from literature. The total number of events and the direct medical cost per 100 patient-years in the genotyped and non-genotyped groups were 9.58 and USD155,700, and, 10.48 and USD 150,500, respectively. The marginal cost per additional major bleeding averted in the genotyped group was USD 5,778. The model was sensitive to the variation of the cost and reduction of bleeding rate in the intensified anticoagulation service. In conclusion, the pharmacogenetics-oriented management of warfarin therapy is potentially more effective in preventing bleeding with a marginal cost. The cost-effectiveness of this treatment scheme depends on the relative cost and effectiveness of a pharmacogenetics-oriented intensified anticoagulation service comparing to the standard AC care.

scholarly journals Use of mHealth Devices to Screen for Atrial Fibrillation: Cost-Effectiveness Analysis (Preprint)

2020 ◽  
Author(s):  
Godwin D Giebel
Keyword(s):  
Atrial Fibrillation ◽  
Cost Effectiveness ◽  
Economic Burden ◽  
Health Care Systems ◽  
Anticoagulation Therapy ◽  
Risk Scores ◽  
Increased Risk ◽  
Care Systems ◽  
Additional Costs ◽  
The Cost

BACKGROUND With an estimated prevalence of around 3% and an about 2.5-fold increased risk of stroke, atrial fibrillation (AF) is a serious threat for patients and a high economic burden for health care systems all over the world. Patients with AF could benefit from screening through mobile health (mHealth) devices. Thus, an early diagnosis is possible with mHealth devices, and the risk for stroke can be markedly reduced by using anticoagulation therapy. OBJECTIVE The aim of this work was to assess the cost-effectiveness of algorithm-based screening for AF with the aid of photoplethysmography wrist-worn mHealth devices. Even if prevented strokes and prevented deaths from stroke are the most relevant patient outcomes, direct costs were defined as the primary outcome. METHODS A Monte Carlo simulation was conducted based on a developed state-transition model; 30,000 patients for each CHA<sub>2</sub>DS<sub>2</sub>-VASc (Congestive heart failure, Hypertension, Age≥75 years, Diabetes mellitus, Stroke, Vascular disease, Age 65-74 years, Sex category [female]) score from 1 to 9 were simulated. The first simulation served to estimate the economic burden of AF without the use of mHealth devices. The second simulation served to simulate the economic burden of AF with the use of mHealth devices. Afterwards, the groups were compared in terms of costs, prevented strokes, and deaths from strokes. RESULTS The CHA<sub>2</sub>DS<sub>2</sub>-VASc score as well as the electrocardiography (ECG) confirmation rate had the biggest impact on costs as well as number of strokes. The higher the risk score, the lower were the costs per prevented stroke. Higher ECG confirmation rates intensified this effect. The effect was not seen in groups with lower risk scores. Over 10 years, the use of mHealth (assuming a 75% ECG confirmation rate) resulted in additional costs (€1=US $1.12) of €441, €567, €536, €520, €606, €625, €623, €692, and €847 per patient for a CHA<sub>2</sub>DS<sub>2</sub>-VASc score of 1 to 9, respectively. The number of prevented strokes tended to be higher in groups with high risk for stroke. Higher ECG confirmation rates led to higher numbers of prevented strokes. The use of mHealth (assuming a 75% ECG confirmation rate) resulted in 25 (7), –68 (–54), 98 (–5), 266 (182), 346 (271), 642 (440), 722 (599), 1111 (815), and 1116 (928) prevented strokes (fatal) for CHA<sub>2</sub>DS<sub>2</sub>-VASc score of 1 to 9, respectively. Higher device accuracy in terms of sensitivity led to even more prevented fatal strokes. CONCLUSIONS The use of mHealth devices to screen for AF leads to increased costs but also a reduction in the incidence of stroke. In particular, in patients with high CHA<sub>2</sub>DS<sub>2</sub>-VASc scores, the risk for stroke and death from stroke can be markedly reduced.

scholarly journals Use of mHealth Devices to Screen for Atrial Fibrillation: Cost-Effectiveness Analysis

10.2196/20496 ◽  
2020 ◽  
Vol 8 (10) ◽  
pp. e20496
Author(s):  
Godwin D Giebel
Keyword(s):  
Atrial Fibrillation ◽  
Cost Effectiveness ◽  
Economic Burden ◽  
Health Care Systems ◽  
Anticoagulation Therapy ◽  
Risk Scores ◽  
Increased Risk ◽  
Care Systems ◽  
Additional Costs ◽  
The Cost

Background With an estimated prevalence of around 3% and an about 2.5-fold increased risk of stroke, atrial fibrillation (AF) is a serious threat for patients and a high economic burden for health care systems all over the world. Patients with AF could benefit from screening through mobile health (mHealth) devices. Thus, an early diagnosis is possible with mHealth devices, and the risk for stroke can be markedly reduced by using anticoagulation therapy. Objective The aim of this work was to assess the cost-effectiveness of algorithm-based screening for AF with the aid of photoplethysmography wrist-worn mHealth devices. Even if prevented strokes and prevented deaths from stroke are the most relevant patient outcomes, direct costs were defined as the primary outcome. Methods A Monte Carlo simulation was conducted based on a developed state-transition model; 30,000 patients for each CHA2DS2-VASc (Congestive heart failure, Hypertension, Age≥75 years, Diabetes mellitus, Stroke, Vascular disease, Age 65-74 years, Sex category [female]) score from 1 to 9 were simulated. The first simulation served to estimate the economic burden of AF without the use of mHealth devices. The second simulation served to simulate the economic burden of AF with the use of mHealth devices. Afterwards, the groups were compared in terms of costs, prevented strokes, and deaths from strokes. Results The CHA2DS2-VASc score as well as the electrocardiography (ECG) confirmation rate had the biggest impact on costs as well as number of strokes. The higher the risk score, the lower were the costs per prevented stroke. Higher ECG confirmation rates intensified this effect. The effect was not seen in groups with lower risk scores. Over 10 years, the use of mHealth (assuming a 75% ECG confirmation rate) resulted in additional costs (€1=US $1.12) of €441, €567, €536, €520, €606, €625, €623, €692, and €847 per patient for a CHA2DS2-VASc score of 1 to 9, respectively. The number of prevented strokes tended to be higher in groups with high risk for stroke. Higher ECG confirmation rates led to higher numbers of prevented strokes. The use of mHealth (assuming a 75% ECG confirmation rate) resulted in 25 (7), –68 (–54), 98 (–5), 266 (182), 346 (271), 642 (440), 722 (599), 1111 (815), and 1116 (928) prevented strokes (fatal) for CHA2DS2-VASc score of 1 to 9, respectively. Higher device accuracy in terms of sensitivity led to even more prevented fatal strokes. Conclusions The use of mHealth devices to screen for AF leads to increased costs but also a reduction in the incidence of stroke. In particular, in patients with high CHA2DS2-VASc scores, the risk for stroke and death from stroke can be markedly reduced.

scholarly journals Cost-Effectiveness of Colorectal Cancer Genetic Testing

2021 ◽  
Vol 18 (16) ◽  
pp. 8330
Author(s):  
Abdul Rahman Ramdzan ◽  
Mohd Rizal Abdul Manaf ◽  
Azimatun Noor Aizuddin ◽  
Zarina A. Latiff ◽  
Keng Wee Teik ◽  
...  
Keyword(s):  
Colorectal Cancer ◽  
Genetic Testing ◽  
Cost Effectiveness ◽  
Cancer Survival ◽  
Screening Method ◽  
Targeted Prevention ◽  
Activity Based Costing ◽  
Cross Sectional ◽  
Increased Risk ◽  
The Cost

Colorectal cancer (CRC) remains the second leading cause of cancer-related deaths worldwide. Approximately 3–5% of CRCs are associated with hereditary cancer syndromes. Individuals who harbor germline mutations are at an increased risk of developing early onset CRC, as well as extracolonic tumors. Genetic testing can identify genes that cause these syndromes. Early detection could facilitate the initiation of targeted prevention strategies and surveillance for CRC patients and their families. The aim of this study was to determine the cost-effectiveness of CRC genetic testing. We utilized a cross-sectional design to determine the cost-effectiveness of CRC genetic testing as compared to the usual screening method (iFOBT) from the provider’s perspective. Data on costs and health-related quality of life (HRQoL) of 200 CRC patients from three specialist general hospitals were collected. A mixed-methods approach of activity-based costing, top-down costing, and extracted information from a clinical pathway was used to estimate provider costs. Patients and family members’ HRQoL were measured using the EQ-5D-5L questionnaire. Data from the Malaysian Study on Cancer Survival (MySCan) were used to calculate patient survival. Cost-effectiveness was measured as cost per life-year (LY) and cost per quality-adjusted life-year (QALY). The provider cost for CRC genetic testing was high as compared to that for the current screening method. The current practice for screening is cost-saving as compared to genetic testing. Using a 10-year survival analysis, the estimated number of LYs gained for CRC patients through genetic testing was 0.92 years, and the number of QALYs gained was 1.53 years. The cost per LY gained and cost per QALY gained were calculated. The incremental cost-effectiveness ratio (ICER) showed that genetic testing dominates iFOBT testing. CRC genetic testing is cost-effective and could be considered as routine CRC screening for clinical practice.

Comparison of Cost-Effectiveness of Anticoagulation with Dabigatran, Rivaroxaban and Apixaban in Patients with Non-Valvular Atrial Fibrillation Across Countries

Blood ◽  
2012 ◽  
Vol 120 (21) ◽  
pp. 1164-1164 ◽  
Author(s):  
Martin Krejczy ◽  
Job Harenberg ◽  
Svetlana Marx ◽  
Konrad Obermann ◽  
Martin Wehling
Keyword(s):  
Cost Effectiveness ◽  
Markov Model ◽  
Case Analysis ◽  
Base Case ◽  
German Population ◽  
Base Case Analysis ◽  
Chads2 Score ◽  
Increased Risk ◽  
Markov Decision Model ◽  
The Cost

Abstract Abstract 1164 The three new oral anticoagulants (NOAC) dabigatran 110mg bid and 150mg bid, investigated in the RE-LY trial, rivaroxaban 20mg od of the ROCKET trial, and apixaban 5mg bid of the ARISTOTLE trial showed equivalent or superior efficacy and safety compared to warfarin in these patients. We performed a cost-effectiveness analysis for these NOACs in Germany and compared the quality of life (QALY), incremental cost effectiveness ratios (ICER), and total costs across those countries form where these data are published. The base case population was a hypothetical cohort of patients 65 years or older with AF who were at increased risk for stroke (CHADS2-score >1) and had no contraindications to anticoagulation. The time horizon was based on the life expectancy of the German population. The QALYs, health insurance costs, and ICER for the NOACs compared with warfarin were calculated for each study. The sensitivity analysis was performed for different base case prices. The Markov decision model was adopted using the TreeAge Pro 2011 program. The data of the outcomes of ischemic stroke and cerebral embolism, major and intracerebral haemorrhage, myocardial infarction, and mortality were taken from the 3 studies comparing the NOAC with INR-adjusted warfarin. Prices for clinical events and for outpatient care were taken from the institute for payment regulations in German hospitals (InEK). The base-case analysis of a 65 years old person with a >2 CHADS2 score using the data from the RE-LY study resulted in 11.41 QALYs for warfarin, 11.53 QALYs for dabigatran 110mg bid, 11.66 QALYs for dabigatran 150 mg bid. ICERs per QALY were 49640€ for dabigatran 110 mg bid and 49590€ for dabigatran 150 mg bid versus warfarin. The same base-case analysis using the data from the ROCKET AF study resulted in 10.79 QALYs for warfarin versus 11.05 QALYs for rivaroxaban. ICERs per QALY were 48980€ for rivaroxaban versus warfarin. The base-case analysis using the data from the ARISTOTLE study resulted and 11.04 QALYs for warfarin versus 11.38 QALYs for apixaban. ICERs per QALY were 49720€ for apixaban versus warfarin. According the Markov Model the daily value based daily prices were 1.25€ for dabigatran 110 mg bid, 2.50€ for dabigatran 150 mg bid, 2.60€ for rivaroxaban, and 3.10€ for apixaban in Germany. The model was highly sensitive to the daily costs for the NOACs but relatively insensitive to other model inputs. Calculating the range of NOAC prices from 0.2 to 10 Euro versus the ICERs dabigatran 110 mg bid produced the highest increase of ICERs over this range of daily costs (Tukey-Kramer test, p<0.05) Comparing these data across countries using the published data shows that the willingness to pay per QALY as well as differences in treatment costs between substantially influences the daily prices of the NOACs. The data demonstrate the necessity to analyse the cost-effectiveness separately for every study due to differences in the INR-adjusted warfarin treated control group. The better the outcome during treatment with warfarin the lower is the benefit of the NOAC. The tendency of the cost-effectiveness calculated by the Markov model is comparable across countries. Disclosures: No relevant conflicts of interest to declare.

Cost-Effectiveness Analysis of Warfarin Versus Low-Molecular Weight Heparin for the Treatment of Malignancy-Associated Venous Thromboembolism

Blood ◽  
2015 ◽  
Vol 126 (23) ◽  
pp. 746-746 ◽  
Author(s):  
Nathan T. Connell ◽  
Gregory A. Abel ◽  
Jean M. Connors
Keyword(s):  
Molecular Weight ◽  
Sensitivity Analysis ◽  
Cost Effectiveness ◽  
Major Bleeding ◽  
Odds Ratio ◽  
Low Molecular Weight Heparin ◽  
Low Molecular Weight ◽  
The Mean ◽  
Recurrent Vte ◽  
The Cost

Introduction: Patients with active malignancy who develop venous thromboembolism (VTE) have historically been anticoagulated with a vitamin K antagonist (VKA) such as warfarin. The CLOT study (Lee et al., NEJM, 2003) demonstrated that injection with the low-molecular weight heparin (LMWH) dalteparin was better than warfarin at preventing recurrence of VTE in cancer patients, which changed clinical practice in the United States; however, a subsequent competing risks analysis (Parpia et al., Contemp Clin Trials, 2011) suggested the magnitude of this benefit may be less than previously believed. Neither patient-focused measures of utility nor the cost of each strategy have been evaluated in the current treatment era. We aimed to characterize the effectiveness and costs associated with these two management strategies for malignancy-associated VTE. Methods: We constructed a Markov state transition model to compare the cost-effectiveness of LMWH to VKA therapy for treatment of malignancy-associated thrombosis from a societal perspective. The model had 4 health states: initial anticoagulation, extended anticoagulation, no anticoagulation, and deceased. Cycle-length was 6 months with a lifetime horizon. Potential events in each cycle included recurrent VTE and death from recurrent VTE, major bleeding and death from major bleeding, minor bleeding, and death from other causes. Model inputs for event probabilities, costs, and utility were obtained from previously published literature (e.g., the ONCENOX, Main-LITE, CLOT, CANTHANOX, and CATCH trials); while no specific data exist for the utility of each strategy for treatment of malignancy-associated VTE, we assumed they would be similar to utilities previously published for non-malignant VTE, and performed sensitivity analysis to assess the robustness of our results. Microsimulation of 1000 trials was performed to calculate mean quality-adjusted life-years (QALYs) and costs associated with the two anticoagulation strategies. Results: Using a fixed effects model, the meta-analytic estimates of the odds ratio for major bleeding from LMWH as compared to VKA therapy was 0.99 (95% CI 0.65 - 1.50). The odds ratio for recurrent VTE while on LMWH as compared to VKA was 0.55 (95% CI 0.40 - 0.75) in favor of LMWH. The mean cost of the VKA strategy was $6,383.39 (±$5174.56) and for the LMWH strategy it was $64,975.83 (±$3,4743.63). The mean effectiveness of the VKA strategy was 1.19 QALYs (range 0.20 - 7.51); for the LMWH strategy it was 1.46 QALYs (range 0.20 - 9.03), resulting in a mean increase of 0.27 QALYs (Figure). The incremental cost-effectiveness ratio (ICER) was thus $221,281.83 per QALY. One-way sensitivity analysis evaluating the utility of the LMWH strategy from 0 - 1 revealed that VKA was always the preferred strategy at a willingness to pay (WTP) threshold of $100,000 per QALY. Conclusions: While LMWH is an effective treatment for malignancy-associated VTE, we found that it offers only a small gain in QALYs compared to VKAs, and that this gain is associated with a significant increase in cost. Our data suggest that LMWH is not a cost-effective strategy when applied to all patients with malignancy-associated VTE and that VKAs may be a reasonable alternative to LMWH. Figure 1. Figure 1. Disclosures No relevant conflicts of interest to declare.

scholarly journals PCV56 THE COST-EFFECTIVENESS LANDSCAPE OF GENETIC TESTING WITH WARFARIN THERAPY

2007 ◽  
Vol 10 (3) ◽  
pp. A53
Author(s):  
LM Meckley ◽  
MJF Austin ◽  
LP Garrison ◽  
DL Veenstra
Keyword(s):  
Genetic Testing ◽  
Cost Effectiveness ◽  
Warfarin Therapy ◽  
The Cost

Continuation of Anti-TNF in Patients With Ulcerative Colitis in Remission Is Not Cost-effective Compared With Treatment Withdrawal: A Markov Model

2020 ◽  
Author(s):  
Remi Mahmoud ◽  
Chris van Lieshout ◽  
Geert W J Frederix ◽  
Bindia Jharap ◽  
Bas Oldenburg
Keyword(s):  
Ulcerative Colitis ◽  
Health Care ◽  
Cost Effectiveness ◽  
Markov Model ◽  
Cost Effective ◽  
Health Care Expenditures ◽  
Increased Risk ◽  
The Cost ◽  
Cost Effectiveness Threshold ◽  
Effectiveness Threshold

Abstract Background and Aims Anti-tumour necrosis factor alpha [anti-TNF] treatment accounts for 31% of health care expenditures associated with ulcerative colitis [UC]. Withdrawal of anti-TNF in patients with UC in remission may decrease side effects and infections, while promoting cost containment. Approximately 36% of patients relapse within 12–24 months of anti-TNF withdrawal, but reintroduction of treatment is successful in 80% of patients. We aimed to evaluate the cost-effectiveness of continuation versus withdrawal of anti-TNF in patients with UC in remission. Methods We developed a Markov model comparing cost-effectiveness of anti-TNF continuation versus withdrawal, from a health care provider perspective. Transition probabilities were calculated from literature, or estimated by an expert panel of 11 gastroenterologists. Deterministic and probabilistic sensitivity analyses were performed to account for assumptions and uncertainty. The cost-effectiveness threshold was set at an incremental cost-effectiveness ratio of €80,000 per quality-adjusted life-year [QALY]. Results At 5 years, anti-TNF withdrawal was less costly [-€10,781 per patient], but also slightly less effective [-0.04 QALY per patient] than continued treatment. Continuation of anti-TNF compared with withdrawal costs €300,390/QALY, exceeding the cost-effectiveness threshold. Continued therapy would become cost-effective if the relapse rate following anti-TNF withdrawal was ≥43% higher, or if adalimumab or infliximab [biosimilar] prices fell below €87/40 mg and €66/100 mg, respectively. Conclusions Continuation of anti-TNF in UC patients in remission is not cost-effective compared with withdrawal. A stop-and-reintroduction strategy is cost-saving but is slightly less effective than continued therapy. This strategy could be improved by identifying patients at increased risk of relapse.

Cost-effectiveness of influenza vaccination of adult cancer patients

2006 ◽  
Vol 24 (18_suppl) ◽  
pp. 6079-6079
Author(s):  
E. B. Avritscher ◽  
C. D. Cooksley ◽  
J. M. Geraci ◽  
B. N. Bekele ◽  
S. B. Cantor ◽  
...  
Keyword(s):  
Cost Effectiveness ◽  
Influenza Vaccine ◽  
Cancer Patients ◽  
Vaccination Strategy ◽  
Vaccine Effectiveness ◽  
Third Party ◽  
Decision Analytic Model ◽  
Accounting System ◽  
Increased Risk ◽  
The Cost

6079 Background: Despite recommendations to immunize all patients at increased risk from underlying immunosuppressive disease against influenza, many insurance plans do not cover the vaccine. We analyzed the cost-effectiveness of vaccinating adult cancer patients against influenza from the perspective of a third-party payer. Methods: We developed a decision-analytic model using epidemiological, vaccine effectiveness, resource utilization, cost, and utility data from published sources, supplemented with data collected from our institutional accounting system. Two strategies were compared: vaccination of adult cancer patients against influenza, and no vaccination. The cost-effectiveness analysis included charges (inflated to 2005 US$) for vaccination, influenza-related hospitalizations, physician and emergency visits, and the average wholesale price for prescription drugs and influenza vaccine. The base-case patient for the model was assumed to be a 67-year-old cancer patient (the median age at initial cancer diagnosis - all sites - for the 1998–2002 SEER population) with active disease. Results: The effectiveness of the no vaccination strategy was 4.665 QALYs at a cost of $95.23. The effectiveness of the influenza vaccine was 4.672 QALYs at a cost of $70.73. Thus, the vaccination strategy provided an incremental effectiveness of 0.007 QALYs over the no vaccination strategy at a reduction in cost of $24.50. Based on these gains, we estimate that vaccination of all adult cancer patients could potentially save third-party payers over $87 million in addition to gains in clinical benefits. The model was not sensitive to plausible changes in cancer survival, incidence of influenza, vaccine effectiveness, vaccine price, and risk of influenza-related hospitalization. Conclusions: Influenza vaccine is cost-effective for adult cancer patients. Health plans should expand their coverage to include the vaccine for adult patients with cancer. No significant financial relationships to disclose.

Venous thromboembolism prophylaxis in ambulatory cancer patients initiating chemotherapy: A cost-effectiveness analysis.

2020 ◽  
Vol 38 (15_suppl) ◽  
pp. 7074-7074
Author(s):  
Emma Ryan ◽  
Julia Salinaro ◽  
Laura J Havrilesky ◽  
Brittany Anne Davidson
Keyword(s):  
Venous Thromboembolism ◽  
Cost Effectiveness ◽  
Cancer Patients ◽  
Major Bleeding ◽  
Cost Effective ◽  
Bleeding Events ◽  
Vte Prophylaxis ◽  
Effectiveness Analysis ◽  
The Cost ◽  
Prophylaxis Strategy

7074 Background: Venous thromboembolism (VTE) is a major cause of morbidity and mortality among cancer patients. The Apixaban for the Prevention of Venous Thromboembolism in High-Risk Ambulatory Cancer Patients (AVERT) randomized controlled trial concluded that apixaban is a safe and effective option for VTE prophylaxis in high-risk ambulatory cancer patients initiating a new chemotherapy regimen. We performed a cost-effectiveness analysis from a health system perspective to determine if apixaban is a feasible prophylactic strategy for this population. Methods: A decision model was created from a third party payer perspective with a time horizon of 6 months, based on the treatment arms of the AVERT trial: (1) apixaban 2.5 mg twice daily for 6 months during active chemotherapy versus (2) placebo. Rates of VTE (4.2% apixaban vs 10.2% placebo), major bleeding (3.5% vs 1.8%) and clinically relevant nonmajor bleeding (CRNMB) (7.3% vs 5.5%) were modeled from the results of the AVERT trial. Cost estimates for treatments and events were obtained from wholesale drug costs, previously published studies and Medicare reimbursement data, and adjusted for inflation to 2018 dollars. Quality adjusted life years were calculated based on previously published utility values for the health states of advanced cancer, DVT, PE, and major bleeding events. An exploratory analysis was performed comparing prophylactic aspirin to no prophylaxis assuming a VTE rate of 7.2%, major bleeding rate of 3.5%, and CRNMB rate of 7.3%, based on the conservative assumptions that while aspirin may not be as effective at preventing VTE, the rate of clinically significant bleeding events would be similar or greater than that of apixaban. Results: In the base case model, apixaban is more costly and more effective than placebo (ICER = $5,013,190/QALY), and the cost per VTE prevented in the apixaban arm is $33,000. In one-way sensitivity analysis, if the cost of apixaban were reduced by 40% from $3,197 to $1,250 for a 6 month course, this could potentially be a cost-effective prophylaxis strategy with an ICER less than $100,000/QALY. In the alternative analysis, aspirin dominates placebo as it is both more effective and less expensive, and remains cost-effective even when the rate of clinically recognized bleeding with aspirin exceeds 15%. Conclusions: Further investigation into less costly prophylactic options such as generic direct oral anticoagulants (once available) and aspirin is warranted prior to broader implementation of a VTE prophylaxis strategy in this population.

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