Evaluating the Importance of Heterogeneity of Treatment Effect: Variation in Patient Utilities Can Influence Choice of the "Optimal" Oral Anticoagulant for Atrial Fibrillation
Evaluating the Importance of Heterogeneity of Treatment Effect: Variation in Patient Utilities Can Influence Choice of the "Optimal" Oral Anticoagulant for Atrial Fibrillation
复制标题
DOI：
10.1016/j.jval.2016.03.1835
复制
发表时间：
2016-07-01
期刊：
影响因子：
4.5
通讯作者：
Ollendorf, Daniel A.
中科院分区：
文献类型：
--
作者：
Cameron, Christopher G.;Synnott, Patricia G.;Ollendorf, Daniel A.
目的：研究房颤患者抗凝治疗效果(HTE)在不同亚组间的异质性，这些亚组由1)临床特征和2)治疗利弊的患者效用差异决定。方法：我们重新分析了一项已发表的网络荟萃分析的汇总数据，该分析比较了四种抗凝剂(阿皮沙班、达比卡特兰、依多沙班和利伐沙班)以及华法林。每种药物在七个亚组中产生中风/系统性血栓(SE)和大出血的事件发生率，并根据临床表现进行排名。公用事业是从国家目录中衍生出来的，然后应用于生成惠益的汇总衡量标准。对任何两种药物之间的选择进行了一系列看似合理的效用值的检查，这些值被定义为中风/SE和大出血的四分位数范围。结果：在临床和效用调整的分析中，几乎没有明显的HTE。达比卡兰150 mg的卒中/SE发生率最低，依多沙班30 mg的大出血发生率最低。当效用在一个合理的效用范围内变化时，可以观察到更大的hte。例如，在75岁及以上的患者中，当使用平均效用估计时，达比加兰150毫克比依多沙班30毫克更受欢迎。然而，对于大出血和卒中/SE，首选药物将分别在合理的实用阈值0.6和0.7处发生变化。在所有可能的比较中，近25%的人会在看似合理的实用范围内看到首选治疗的变化。结论：房颤患者抗凝药物的最佳选择因临床特点和合理的用药范围而异。
Objectives: To investigate heterogeneity of treatment effect (HTE) for anticoagulants in atrial fibrillation across subgroups defined by 1) clinical characteristics and 2) variation in patient utilities for benefits and harms of treatment. Methods: We reanalyzed aggregate data from a published network meta-analysis that compared four anticoagulants for atrial fibrillation (apixaban, dabigatran, edoxaban, and rivaroxaban) as well as warfarin. Event rates for stroke/systemic embolism (SE) and major bleeding were generated for each agent across seven subgroups, and rankings were developed on the basis of clinical performance. Utilities were derived from a national catalog and then applied to generate summary measures of benefit. The choice between any two agents was examined across a range of plausible utility values, defined as the interquartile range for stroke/SE and major bleeding. Results: Little HTE was apparent in clinical and utility-adjusted analyses. Dabigatran 150 mg produced the lowest rates of stroke/SE, and edoxaban 30 mg had the lowest rate of major bleeding. Greater HTE was observed when utilities were varied across a plausible utility range. For example, among patients 75 years and older, dabigatran 150 mg would be preferred over edoxaban 30 mg when mean utility estimates are used. The preferred agent, however, would change at plausible utility thresholds of 0.6 and 0.7 for major bleeding and stroke/SE, respectively. Nearly 25% of all possible comparisons would see a change in preferred treatment within the plausible utility range. Conclusions: The optimal choice of anticoagulant in atrial fibrillation differs across subgroups defined by clinical characteristics and reasonable ranges of utilities.