Cost-effectiveness analysis of antithrombotic therapy in nonurgent percutaneous coronary intervention.
OBJECTIVE
To perform a cost-effectiveness analysis comparing three treatment approaches during nonurgent percutaneous coronary intervention (PCI): bivalirudin with provisional glycoprotein (GP) IIb-IIIa inhibitor therapy, unfractionated heparin (UFH) with eptifibatide, and UFH with abciximab.


METHODS
Literature-based decision model from an institutional perspective.


METHODS
Patient data from the Randomized Evaluation in PCI Linking Angiomax to Reduced Clinical Events (REPLACE)-2 study and three other randomized controlled trials that included UFH and routine GP IIb-IIIa inhibitor (eptifibatide or abciximab) therapy. All included studies were comparable based on patient population, procedural techniques, and general treatment approaches.


RESULTS
We included patient populations undergoing contemporary nonurgent PCI to identify probabilities of success or complications (myocardial infarction, urgent revascularization, thrombocytopenia, and major or minor bleeding at 30 days). Costs were assigned to each outcome by incorporating diagnosis-related group-- and/or Current Procedural Terminology--associated costs, institutional drug acquisition costs, and unit replacement costs of platelets and red blood cells. In the base-case analysis, the use of bivalirudin with provisional GP IIb-IIIa inhibitor therapy dominated the UFH and planned GP IIb-IIIa inhibitor approach: UFH with eptifibatide was 74 US dollars more expensive and 1.2% less effective, and UFH with abciximab was 777 US dollars more expensive and 2.3% less effective. Sensitivity analyses indicated that the model results were robust, but also revealed that bivalirudin lost its cost-effectiveness, resulting in UFH with eptifibatide becoming more cost-effective, when two or more vials of bivalirudin were necessary in greater than 27% of cases or when the use of provisional GP IIb-IIIa inhibitor therapy exceeded 20%.


CONCLUSIONS
This analysis indicates that bivalirudin with provisional GP IIb-IIIa inhibitor therapy is the most cost-effective antithrombotic treatment strategy in nonurgent PCI when its use and dosing are consistent with the REPLACE-2 trial.
Summers
Kelly M
KM
School of Pharmacy, University of Maryland, Baltimore, USA.
Holdford
David A
DA
Crouch
Michael A
MA
D000077284:Abciximab; D015906:Angioplasty, Balloon, Coronary; D000911:Antibodies, Monoclonal / Q000627:therapeutic use; D000991:Antithrombins / Q000191:economics / Q000627:therapeutic use; D003327:Coronary Disease / Q000188:drug therapy* / Q000453:epidemiology; D003362:Cost-Benefit Analysis; D016208:Databases, Factual; D003661:Decision Support Techniques; D016527:Drug Costs; D000077542:Eptifibatide; D005343:Fibrinolytic Agents / Q000008:administration & dosage / Q000191:economics* / Q000627:therapeutic use*; D006493:Heparin / Q000191:economics / Q000627:therapeutic use; D006629:Hirudins / Q000191:economics; D006801:Humans; D007140:Immunoglobulin Fab Fragments / Q000627:therapeutic use; D010446:Peptide Fragments / Q000191:economics / Q000627:therapeutic use; D010455:Peptides / Q000191:economics / Q000627:therapeutic use; D010975:Platelet Aggregation Inhibitors / Q000191:economics / Q000627:therapeutic use; D019039:Platelet Glycoprotein GPIIb-IIIa Complex / Q000037:antagonists & inhibitors; D011183:Postoperative Complications / Q000191:economics* / Q000517:prevention & control*; D016032:Randomized Controlled Trials as Topic; D011994:Recombinant Proteins / Q000191:economics / Q000627:therapeutic use; D016896:Treatment Outcome
D000911:Antibodies, Monoclonal; D000991:Antithrombins; D005343:Fibrinolytic Agents; D006629:Hirudins; D007140:Immunoglobulin Fab Fragments; D010446:Peptide Fragments; D010455:Peptides; D010975:Platelet Aggregation Inhibitors; D019039:Platelet Glycoprotein GPIIb-IIIa Complex; D011994:Recombinant Proteins; D006493:Heparin; D000077542:Eptifibatide; C074619:bivalirudin; D000077284:Abciximab