Abstract 3504: Cost-Effectiveness of Clopidogrel in Percutaneous Coronary Intervention Based on a Meta-Analysis of PCI-CURE, CREDO and PCI-CLARITY
Objective: The PCI-CURE, CREDO and PCI-CLARITY trials have shown the efficacy of pre-treatment and long-term treatment with clopidogrel in PCI for a range of patients and settings, including non-ST-segment elevation acute coronary syndromes, elective PCI and patients with ST-segment elevation myocardial infarction (MI) receiving fibrinolytics. Our objective was to conduct a comprehensive cost-effectiveness analysis of clopidogrel in PCI based on a meta-analysis of the clinical data.
Methods: A combined decision tree and Markov model was created to capture the short- and long-term costs and effects of alternative treatments on ischemic events following PCI. The relative risks of the combined endpoint MI and cardiovascular death and of major bleedings with clopidogrel treatment prior to PCI and for up to 12 months were based on a fixed effects meta-analysis. The risk of death, MI and stroke in an untreated population and long-term survival were taken from the Swedish hospital and death registers. A societal perspective was used in Sweden and a payer perspective in Germany and France. Costs are stated in € 2006 and effectiveness measured in life-years gained (LYG).
Results: The pooled effects of clopidogrel versus placebo (in addition to aspirin) on the combined endpoint showed a relative risk of 0.711 (95% CI 0.57– 0.89; p = 0.003) at 30 days and 0.745 (95% CI 0.62– 0.89; p = 0.002) at the end of follow-up. The pooled effects on major bleedings indicated a non-significant (p > 0.05) increase in risk and were included as a conservative assumption. Including direct costs only, pre-treatment with clopidogrel compared with aspirin alone is a dominant strategy. Long-term treatment compared with one-month treatment leads to around 0.13 LYG at an incremental cost of € 537 in Sweden, € 709 in Germany and € 494 in France. The corresponding incremental cost-effectiveness ratios range from € 3634/LYG to € 5513/LYG. Using a theoretical willingness to pay threshold of € 30000 per LYG, at least 99% of simulations are cost-effective.
Conclusions: Pre-treatment and long-term treatment of PCI patients with clopidogrel for up to one year is cost-effective in a range of patient groups and settings, with predicted cost-effectiveness ratios well below generally accepted thresholds.