title: Cost-effectiveness of bivalirudin versus heparin plus glycoprotein IIb/IIIa inhibitor in the treatment of non-ST-segment elevation acute coronary syndromes.
abstract: OBJECTIVE
  This study sought to assess the cost-effectiveness of bivalirudin versus heparin plus glycoprotein IIb/IIIa inhibitor (GPI) in thienopyridine-treated non-ST-segment elevation acute coronary syndrome (NSTE-ACS) patients undergoing early or urgent invasive management, from a United Kingdom National Health Service perspective.
  
  
  METHODS
  A decision-analytic model with lifelong time horizon was populated with event risks and resource use parameters derived from the Acute Catheterization and Urgent Intervention Triage Strategy (ACUITY) trial raw data. In a parallel analysis, key comparator strategy inputs came from Global Registry of Acute Coronary Events (GRACE) patients enrolled in the United Kingdom. Upstream and catheter laboratory-initiated GPI were assumed to be tirofiban and abciximab, respectively. Life expectancy of first-year survivors, unit costs, and health-state utilities came from United Kingdom sources. Costs and effects were discounted at 3.5%. Incremental cost-effectiveness ratios (ICERs) were expressed as cost per quality-adjusted life year (QALY) gained.
  
  
  RESULTS
  Higher acquisition costs for bivalirudin were partially offset by lower hospitalization and bleeding costs. In the ACUITY-based analysis, per-patient lifetime costs in the bivalirudin and heparin plus GPI strategies were £10,903 and £10,653, respectively. Patients survived 10.87 and 10.82 years on average, corresponding to 5.96 and 5.93 QALYs and resulting in an ICER of £9,906 per QALY gained. The GRACE-based ICER was £12,276 per QALY gained. In probabilistic sensitivity analysis, 72.1% and 67.0% of simulation results were more cost-effective than £20,000 per QALY gained, in the ACUITY-based and GRACE-based analyses, respectively. Additional scenario analyses implied that greater cost-effectiveness may be achieved in actual clinical practice.
  
  
  CONCLUSIONS
  Treating NSTE-ACS patients undergoing invasive management with bivalirudin is likely to represent a cost-effective option for the United Kingdom, when compared with the current practice of using heparin and a GPI.
authors.affiliation: Institute of Pharmaceutical Medicine, University of Basel, Basel, Switzerland. m.schwenkglenks@unibas.ch
authors.forename: Matthias
authors.initials: M
authors.lastname: Schwenkglenks
authors.forename: John E
authors.initials: JE
authors.lastname: Brazier
authors.forename: Thomas D
authors.initials: TD
authors.lastname: Szucs
authors.forename: Keith A A
authors.initials: KA
authors.lastname: Fox
mesh_terms: D000077284:Abciximab; D054058:Acute Coronary Syndrome / Q000188:drug therapy* / Q000191:economics / Q000628:therapy; D000911:Antibodies, Monoclonal; D000925:Anticoagulants / Q000191:economics* / Q000627:therapeutic use; D003362:Cost-Benefit Analysis; D003663:Decision Trees; D004359:Drug Therapy, Combination; D005260:Female; D017048:Health Care Costs; D006493:Heparin / Q000191:economics* / Q000627:therapeutic use; D006629:Hirudins / Q000191:economics*; D006801:Humans; D007140:Immunoglobulin Fab Fragments; D008297:Male; D008875:Middle Aged; D017059:Models, Econometric; D009204:Myocardial Revascularization; D010446:Peptide Fragments / Q000191:economics* / Q000627:therapeutic use; D019039:Platelet Glycoprotein GPIIb-IIIa Complex / Q000037:antagonists & inhibitors*; D011725:Pyridines; D019057:Quality-Adjusted Life Years; D011994:Recombinant Proteins / Q000191:economics / Q000627:therapeutic use; D016019:Survival Analysis; D000077466:Tirofiban; D014443:Tyrosine / Q000031:analogs & derivatives; D006113:United Kingdom
chemical_list: D000911:Antibodies, Monoclonal; D000925:Anticoagulants; D006629:Hirudins; D007140:Immunoglobulin Fab Fragments; D010446:Peptide Fragments; D019039:Platelet Glycoprotein GPIIb-IIIa Complex; D011725:Pyridines; D011994:Recombinant Proteins; C446540:thienopyridine; D014443:Tyrosine; D006493:Heparin; D000077466:Tirofiban; C074619:bivalirudin; D000077284:Abciximab