Economic evaluation of clopidogrel in acute coronary syndrome patients without ST-segment elevation in Greece: a cost-utility analysis.
BACKGROUND
Current guidelines recommend treatment with antiplatelet and anticoagulant therapy for the secondary prevention of atherothrombotic events among patients with non-ST-segment elevation myocardial infarction (NSTEMI) or unstable angina (UA). The CURE (Clopidogrel in Unstable angina to prevent Recurrent Events) trial has shown that clopidogrel alone or in combination with aspirin is more effective in reducing the risk of atherothrombotic events than aspirin alone in NSTEMI or UA patients. However, in the current climate of financial constraints, the effectiveness of a treatment should be considered in conjunction with its long-term economic costs to determine the best possible care.


OBJECTIVE
To evaluate the cost effectiveness of 1 year of treatment with clopidogrel in addition to aspirin in NSTEMI or UA patients from the third-party-payer perspective in Greece.


METHODS
An existing Markov model consisting of six states (NSTEMI/UA/no event, first year with stroke, history of stroke, first year with myocardial infarction [MI], history of MI and death) was adapted and extended to the Greek healthcare setting for year 2012. Utility values obtained from a Greek national study were assigned to each health state in order to estimate the quality-adjusted life-years (QALYs). Costs assigned to each health state included antiplatelet treatment cost, cost for the management of adverse events and the costs for concomitant medication, hospitalization, outpatient visits, rehabilitation and nursing. Cost effectiveness and cost utility was expressed as the cost per life-year (LY) gained and QALY gained, respectively. A probabilistic sensitivity analysis was conducted.


RESULTS
The Markov analysis predicts a discounted survival of 8.27 years in the aspirin treatment group and 8.41 years in the aspirin plus clopidogrel treatment group. The corresponding discounted QALYs were 6.88 and 7.00, respectively. The cumulated lifetime costs per patient were € 18 779 and € 19 191, for the aspirin and aspirin plus clopidogrel treatment arms, respectively. The incremental cost-effectiveness ratio (ICER) with the addition of clopidogrel was &U20AC;2951 for each LY saved and &U20AC;3541 for each QALY saved. Finally, clopidogrel plus aspirin was found to be cost effective in more than 95% of simulated samples at a threshold of &U20AC;7000 per discounted QALY gained.


CONCLUSIONS
One-year treatment with clopidogrel in addition to aspirin is a cost-effective treatment option for secondary prevention in patients with acute coronary syndrome without ST-segment elevation in Greece.
National School of Public Health, Department of Health Services Management, Athens, Greece. kurlaba@hua.gr
Georgia
G
Kourlaba
Vassilis
V
Fragoulakis
Nikos
N
Maniadakis
D054058:Acute Coronary Syndrome / Q000188:drug therapy* / Q000191:economics* / Q000517:prevention & control; D000368:Aged; D000789:Angina, Unstable / Q000150:complications / Q000188:drug therapy / Q000191:economics*; D001241:Aspirin / Q000191:economics* / Q000627:therapeutic use; D000077144:Clopidogrel; D003198:Computer Simulation; D003362:Cost-Benefit Analysis; D004359:Drug Therapy, Combination / Q000191:economics; D005260:Female; D006115:Greece; D006801:Humans; D008297:Male; D008390:Markov Chains; D018803:Models, Economic; D010975:Platelet Aggregation Inhibitors / Q000191:economics* / Q000627:therapeutic use; D019057:Quality-Adjusted Life Years; D055502:Secondary Prevention / Q000191:economics / Q000379:methods; D016019:Survival Analysis; D013988:Ticlopidine / Q000031:analogs & derivatives* / Q000191:economics / Q000627:therapeutic use
D010975:Platelet Aggregation Inhibitors; D000077144:Clopidogrel; D013988:Ticlopidine; D001241:Aspirin