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A Systematic Review of Economic Aspects of Service Interventions to Increase Anticoagulation Use in Atrial FibrillationFunding N.R.J. is supported by a Wellcome Trust Doctoral Research Fellowship (grant number 203921/Z/16/Z). This project has also received funding from the Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Oxford. F.D.R.H. acknowledges part-funding from the National Institute for Health Research (NIHR) School for Primary Care Research, the NIHR Collaboration for Leadership in Health Research and Care (CLARHC) Oxford, the NIHR Oxford Biomedical Research Centre (BRC, UHT) and the NIHR Oxford Medtech and In-Vitro Diagnostics Co-operative (MIC). C.J.T. is supported by an NIHR Academic Clinical Lectureship. S.P. receives support as an NIHR (National Institute for Health Research) Senior Investigator (NF-SI-0616-10103).
Objective To systematically identify and appraise existing evidence surrounding economic aspects of anticoagulation service interventions for patients with atrial fibrillation.
Methods We searched the published and grey literature up to October 2019 to identify relevant economic evidence in any health care setting. A narrative-synthesis approach was taken to summarise evidence by economic design and type of service intervention, with costs expressed in pound sterling and valued at 2017 to 2018 prices.
Results A total of 13 studies met our inclusion criteria from 1,168 papers originally identified. Categories of interventions included anticoagulation clinics (n = 4), complex interventions (n = 4), decision support tools (n = 3) and patient-centred approaches (n = 2). Anticoagulation clinics were cost-saving compared with usual care (range for mean cost difference: £188–£691 per-patient per-year) with equivalent health outcomes. Only one economic evaluation of a complex intervention was conducted; case management was more expensive than usual care (mean cost difference: £255 per-patient per-year) and the probability of its cost-effectiveness did not exceed 70%. There was limited economic evidence surrounding decision support tools or patient-centred approaches. Targeting service interventions at high-risk groups and those with suboptimal treatment was most likely to result in cost savings.
Conclusion This review revealed some evidence to support the cost-effectiveness of anticoagulation clinics. However, summative conclusions are constrained by a paucity of economic evidence, a lack of direct comparisons between interventions, and study heterogeneity in terms of intervention, comparator and study year. Further research is urgently needed to inform commissioning and service development. Data from this review can inform future economic evaluations of anticoagulation service interventions.
Keywordsatrial fibrillation - anticoagulation - service intervention - economic evaluations - systematic review
N.R.J., C.J.T. and F.D.R.H. devised the idea for the project with input from S.P. and Y.Y. N.R.J. and W.C. conducted data screening, data extraction and quality assessment with guidance and feedback from S.P. N.R.J. wrote the first draft of the manuscript and all authors contributed to subsequent revisions and approved of the final version.
Received: 16 November 2020
Accepted: 18 May 2021
21 May 2021 (online)
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