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PHARMACOECONOMICS

Cost-Effectiveness Analysis of Anticoagulation Strategies in Non-ST-Elevation Acute Coronary Syndromes

Cardiovascular Clinical Pharmacist, Jackson Madison County General Hospital, Jackson, TN

David A Holdford, BSPharm MS PhD

Associate Professor of Pharmacy, Virginia Commonwealth University, MCV Campus, Richmond, VA

Michael A Crouch, PharmD BCPS

Professor and Chair, South University School of Pharmacy, Savannah, GA

Dipen A Patel, BSPharm PhD Candidate

Virginia Commonwealth University, MCV Campus

Reprints: Dr. Crouch, 709 Mall Blvd., Savannah, GA 31406, fax 912/201-8153, mcrouch{at}southuniversity.edu

BACKGROUND: Contemporary studies document the outcomes of unfractionated heparin (UFH), enoxaparin, fondaparinux, and bivalirudin in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS). It remains unclear which anticoagulant regimen is the most cost-effective.

OBJECTIVE: To perform a cost-effectiveness analysis comparing 4 anticoagulant regimens in NSTE-ACS.

METHODS: A decision analysis was conducted from a healthcare provider perspective. Data sources included the SYNERGY, OASIS-5, and ACUITY trials, including 2 subgroup analyses. A decision tree model was created incorporating the outcomes associated with 4 antithrombotic approaches: UFH with eptifibatide, enoxaparin with eptifibatide, bivalirudin alone, and fondaparinux with eptifibatide. The percentage of eptifibatide use in each arm was consistent with clinical trials. Probabilities of complications (eg, myocardial infarction, revascularization, major/minor bleeding at 30 days) were calculated. Costs were assigned to each outcome, incorporating the cost associated with diagnosis-related group and/or current procedural terminology codes, drug acquisition, and red blood cell infusions. Multiple sensitivity analyses were performed.

RESULTS: The base case analysis showed bivalirudin monotherapy to be the least costly regimen ($1131 per average course), and it dominated enoxaparin plus eptifibatide ($1609) and UFH plus eptifibatide ($1739) in cost-effectiveness. The total average cost of fondaparinux with eptifibatide ($1184) was higher than bivalirudin alone, but the combination was more effective, resulting in an incremental cost of $2569 per each additional patient treated without complication. Sensitivity analyses showed the model's results to be sensitive to drug acquisition cost and complication probabilities. Probabilistic sensitivity analyses favored neither bivalirudin nor fondaparinux; however, when 2 or more vials of bivalirudin were necessary, bivalirudin was no longer a cost-effective alternative.

CONCLUSIONS: Bivalirudin is the least costly agent in moderate- to high-risk NSTE-ACS patients managed with an early invasive approach, if its use is consistent with the ACUITY trial. Fondaparinux is the preferred agent in patients undergoing a conservative treatment strategy.

Key Words: acute coronary syndrome, bivalirudin, cost-effectiveness, fondaparinux, low-molecular-weight heparin, unfractionated heparin

Published Online, March 31, 2009. www.theannals.com, DOI 10.1345/aph.1L498