Economic Evaluation of Direct Oral Anticoagulants Versus Low-Molecular Weight Heparin for Cancer-Associated Thrombosis in a Thai University-Affiliated Hospital.

Background/Objectives: Venous thromboembolism (VTE) is an important global health concern associated with considerable morbidity and mortality. Despite established guidelines for VTE treatment, there is a gap between clinical recommendations and their implementation in practice because of limited accessibility, particularly in low- and middle-income countries and among patients with cancer. This study aimed to assess the cost-effectiveness of direct oral anticoagulants (DOACs) on VTE in patients with cancer at a Thai university-affiliated hospital. Methods: A cost-utility analysis using a Markov model was developed to estimate costs and quality-adjusted life-years (QALYs) of DOACs and low-molecular weight heparin (LWMH) in Thai patients with cancer aged over 60 years. The model with eight health states, including CAT on treatment, pulmonary embolism (PE), deep vein thrombosis (DVT), clinically relevant nonmajor bleeding (CRNMB), non-intracranial hemorrhage major bleeding (non-ICH MB), intracranial hemorrhage (ICH), off treatment, and any death, was developed with a one-month cycle length and used to estimate costs and health outcomes from a societal perspective with a lifetime horizon. The efficacy and safety of DOACs compared to LMWH were obtained from a network meta-analysis, while the costs were based on a Thai university hospital database. All costs and outcomes were discounted at 3%, and the Thai societal willingness-to-pay (WTP) threshold (THB 160,000 per QALY gained) was applied. The incremental cost-effectiveness ratio (ICER) was calculated to compare costs and QALYs of the interventions. Results: The total lifetime cost of LMWH was THB 70,928 (USD 2,163), while for apixaban, dabigatran, edoxaban, and rivaroxaban, the costs were THB 26,323 (USD 803), THB 33,667 (USD 1,027), THB 29,570 (USD 902), and THB 22,310 (USD 680), respectively. The QALYs for LMWH, apixaban, dabigatran, edoxaban, and rivaroxaban were 0.771, 0.775, 0.746, 0.759, and 0.770 QALYs, respectively. Compared to LMWH, apixaban provided 0.004 additional QALYs, with a decreased cost of THB 44,605 (USD 1,360), resulting in reduced expenses. On the other hand, dabigatran, edoxaban, and rivaroxaban were also associated with lower lifetime costs but reduced life-years and QALYs when compared with LMWH. Conclusions: This study revealed that apixaban is likely to be the preferred option for treating patients with CAT. However, policy decision-making process should take into account the uncertainties related to the implementation of this practice.