Contents lists available at ScienceDirect Thrombosis Research journal homepage: www.elsevier.com/locate/thromres Full Length Article Cost-effectiveness of warfarin care bundles and novel oral anticoagulants for stroke prevention in patients with atrial fibrillation in Thailand Siok Shen Ng a,b,c , Surakit Nathisuwan d , Arintaya Phrommintikul e , Nathorn Chaiyakunapruk a,f,g, ⁎ a School of Pharmacy, Monash University Malaysia, Bandar Sunway, Malaysia b Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway, Malaysia c Department of Pharmacy, Hospital Melaka, Malaysia d Clinical Pharmacy Division, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand e Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Muang, Chiang Mai, Thailand f College of Pharmacy, University of Utah, Salt Lake City, UT, USA g Asian Centre for Evidence Synthesis in Population, Implementation and Clinical Outcomes (PICO), Health and Well-being Cluster, Global Asia in the 21st Century (GA21) Platform, Monash University Malaysia, Bandar Sunway, Selangor, Malaysia ARTICLE INFO Keywords: Stroke Anticoagulants Atrial fibrillation Anticoagulants Cost-effectiveness Warfarin ABSTRACT Introduction: Novel oral anticoagulants (NOACs) and warfarin care bundles (e.g. genotyping, patient self-testing or self-management) are alternatives to usual warfarin care for stroke prevention in patients with atrial fi- brillation (AF). We aim to evaluate the cost-effectiveness of NOACs and warfarin care bundles in patients with AF in a middle-income country, Thailand. Materials and methods: A Markov model was used to evaluate the economic and treatment outcomes of warfarin care bundles and NOACs compared with usual warfarin care. Cost-effectiveness was assessed from a societal perspective over a lifetime horizon with 3% discount rate in a hypothetical cohort of 65-year-old atrial fi- brillation patients. Input parameters were derived from published literature, meta-analysis and local data when available. The outcome measure was incremental cost per quality-adjusted life years (QALY) gained (ICER). Results: Using USD5104 as the threshold of willingness-to-pay per QALY, patient's self-management of warfarin was cost-effective when compared to usual warfarin care, with an ICER of USD1395/QALY from societal per- spective. All NOACs were not cost-effective in Thailand, with ICER ranging from USD8678 to USD14,247/QALY. When compared to the next most effective intervention, patient's self-testing and genotype-guided warfarin dosing were dominated. In the cost-effectiveness acceptability curve, patient's self-management had the highest probability of being cost-effective in Thailand, approximately 78%. Results were robust over a range of inputs in sensitivity analyses. Conclusions: In Thailand, NOACs were unlikely to be cost-effective at current prices. Conversely, patient's self- management is a highly cost-effective intervention and may be considered for adoption in developing regions with resource-limited healthcare systems. 1. Introduction Atrial fibrillation (AF) is the most common cardiac arrhythmia and affects 1.9% of the Thai population aged more than 65 years [1]. Pa- tients with AF have a five-fold increased risk of stroke, resulting in significant morbidity and mortality [2]. Therefore, stroke prevention is an essential component of AF management. For decades, warfarin has been the only effective oral anticoagulant for stroke prevention in AF [3]. Although inexpensive and effective, it is often associated with in- creased risk of bleeding and poor quality of life due to the need for frequent monitoring. Moreover, the warfarin control in many countries is suboptimal; in Thailand the time in therapeutic range (TTR) is less than 50% [4,5]. Due to the perceived inconvenience associated with usual warfarin care, warfarin care bundles have been introduced and are based on the concept of combining warfarin with another intervention such as gen- otyping, patient’ self-testing or self-management of warfarin and left atrial appendage closure (LAAC) [6]. Warfarin care bundles might op- timize anticoagulation control by either achieving higher TTR value or reduce the dependency for long-term warfarin therapy. https://doi.org/10.1016/j.thromres.2019.11.012 Received 19 August 2019; Received in revised form 24 October 2019; Accepted 11 November 2019 ⁎ Corresponding author at: College of Pharmacy, University of Utah, Salt Lake City, UT, USA. E-mail address: nathorn.chaiyakunapruk@utah.edu (N. Chaiyakunapruk). Thrombosis Research 185 (2020) 63–71 Available online 15 November 2019 0049-3848/ © 2019 Elsevier Ltd. All rights reserved. T