Abstract 18228: Cost-Effectiveness of New Oral Antiplatelet Agents and Testing Strategies During Early Invasive Management of Acute Coronary Syndrome Patients
BACKGROUND: Prasugrel has become available with variable adoption across practices. Incremental cost-effectiveness analysis of prasugrel and other future agents relative to clopidogrel may provide rationale guidance for their appropriate use.
METHODS: A Markov-model with baseline acute coronary syndrome (ACS) health state and subsequent death, nonfatal myocardial infarction, stent thrombosis, urgent revascularization, major bleeding, and malignancy was constructed with 15 one month cycles. Published incremental costs, utilities, and event frequency distributions from randomized trials and series were used to assign transition probabilities and “payoffs” as a function of time. A second model examined modification of therapy at critical time-points based on genetic and platelet function testing assays. Probabilistic 95% confidence intervals were calculated using the parameter distributions in the model.
RESULTS: In ACS patients undergoing an early invasive strategy, prasugrel was dominant over clopidogrel with $9,988+/-2,148 saved per QALY saved in the first month after the index event. In months 2 through 15, prasugrel 10 mg daily had incremental estimated cost of $5,820 +/- 2,136 per QALY saved. In months 2 through 15, prasugrel had estimated incremental cost-effectiveness of $42,225 +/-12,499 per QALY saved compared to generic clopidogrel (at lowest current online overseas price.) A strategy of early routine prasugrel administration in all eligible patients followed by genetic testing for loss-of-function CYP450-2C19 gene alleles to guide maintenance therapy was the most cost-effective strategy reducing overall societal cost by 36 +/- 18% with little compromise in net clinical outcomes.
CONCLUSIONS: The estimated cost-effectiveness of oral antiplatelet adjunctive therapy in ACS patients being managed with an early invasive strategy is time-dependent and optimized by genetic testing. This analysis might help guide rationale selection of oral antiplatelet therapy, reducing arbitrary practice variation.
- © 2011 by American Heart Association, Inc.