Here's a thought experiment: imagine a world where the NOACs are the status quo in use at their current prices and warfarin is the new drug on the block, hyped as being equivalent but dirt cheap. Does anybody really think that warfarin, supported by the same data that Dr. Mandrola and I seem to disagree about, along with all of its challenges would ever get approved and accepted by clinicians on the basis of being an inexpensive alternative? I doubt it.
Dr. Mandrola's math and mine are the same, and he's right that this way of looking at treatment differences based on absolute rather than relative risks provides important insights. We agree that patients should be informed of differences in costs and high stakes outcomes and make their own decisions. We agree that the devil is in the details, but from my perspective, that devil is warfarin. It's almost as effective as the NOACs but the small difference is real and it affects life and death. While warfarin is cheap, NOACs are better and they provide value to many people that is very likely (especially in the case of certain NOACs) cost effective.
I wonder if Dr. Mandrola still stands by his earlier conclusions ...
*Try telling that to Serbia's Milorad Cavic, whom Michael Phelps beat by a thousandth of a second to win his record-tying seventh Olympic gold medal in the 100 meter butterfly. With less than a metre to go, Phelps trailed Cavic, whose fingers were gliding inches away from gold. But Phelps' last half stroke made the difference as his arms flew around and out-touched his competitor. Phelps did the exact same thing in the same event 4 years earlier, winning gold over fellow American, Ian Crocker by just 4 thousands of a second.