How to invest in getting cost-effective technologies into practice? : A framework for value of implementation analysis applied to novel oral anticoagulants

Cost-effective interventions are often implemented slowly and sub-optimally in clinical practice. In such situations, a range of implementation activities may be considered to increase uptake. A framework is proposed to use cost-effectiveness analysis to inform decisions on how best to invest in implementation activities. This framework addresses two key issues: (1) how to account for changes in utilisation in the future in the absence of implementation activities; and (2) how to prioritise implementation efforts between subgroups. A case study demonstrates the framework’s application: novel oral anticoagulants (NOACs) for the prevention of stroke in the National Health Service (NHS) in England and Wales. The results suggest that there is value in additional implementation activities to improve uptake of NOACs, particularly in targeting patients with average or poor warfarin control. At a cost-effectiveness threshold of £20,000 per quality-adjusted life-year (QALY) gained, additional investment in an educational activity that increases the utilisation of NOACs by 5% in all patients currently on warfarin generates an additional 254 QALYs, compared with 973 QALYs in the subgroup with average to poor warfarin control. However, greater value could be achieved with higher uptake of anticoagulation more generally: switching 5% of patients potentially eligible for anticoagulation but currently on no treatment or using aspirin would generate an additional 4,990 QALYs. This work can help health services make decisions on investment at different points of the care pathway or across disease areas in a manner consistent with the value assessment of new interventions.