Long-term cost-effectiveness of clopidogrel in STEMI patients.
BACKGROUND
The COMMIT trial demonstrated that clopidogrel produced a 9% relative reduction in death, reinfarction or stroke (9.2% vs. 10.1%, 95% CI: 0.86-0.97) in ST-elevated myocardial infarction (STEMI) patients.


METHODS
Between 08/1999 and 05/2005, 45,852 STEMI patients were randomized to clopidogrel (n=22,961) or matching placebo (n=22,891) in addition to aspirin. The rate of initial hospitalizations for death, non-fatal myocardial infarction with/without major complications and PCI within 28 days was calculated based on the COMMIT clinical paper. Three CURE papers, concerning non-STEMI patients, were used to estimate the event rates between 29 days and 1 year. Hospitalizations were assigned a diagnosis-related group (DRG). Costs for each DRG were estimated from the Medicare reimbursement rate. Clopidogrel was assumed to be given for 1 year, priced at $4.22/day. Life expectancy gain as a result of the prevention of death, myocardial infarction, and stroke was estimated using Framingham data.


RESULTS
Within 28 days, adding clopidogrel to aspirin is likely a dominant strategy, lowering the event rate (9.2% vs. 10.1%) without an increase in cost ($7791 vs. $7797). Over a lifetime, treating for 1 year with clopidogrel-plus-aspirin produced a gain of 0.1187 life years at an incremental cost of $1269 compared to aspirin alone, resulting in an incremental cost-effectiveness ratio (ICER) of $10,691/life year gained. Sensitivity analyses showed that ICERs for clopidogrel are well below the common benchmark ceiling ratio of $50,000/life year gained.


CONCLUSIONS
Addition of clopidogrel to aspirin, given up to 1 year, in the setting of STEMI is a highly cost-effective strategy.
Zhang
Zefeng
Z
School of Public Health, Nantong University, PR China. zzhang2@emory.edu
Kolm
Paul
P
Mosse
Frederique
F
Jackson
Joseph
J
Zhao
Liping
L
Weintraub
William S
WS
D000368:Aged; D001241:Aspirin / Q000191:economics / Q000627:therapeutic use; D000077144:Clopidogrel; D003362:Cost-Benefit Analysis / Q000191:economics; D003663:Decision Trees; D004311:Double-Blind Method; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000188:drug therapy* / Q000191:economics* / Q000401:mortality; D013988:Ticlopidine / Q000031:analogs & derivatives* / Q000191:economics / Q000627:therapeutic use; D013997:Time Factors; D016896:Treatment Outcome
D000077144:Clopidogrel; D013988:Ticlopidine; D001241:Aspirin