Cost-Effectiveness of Ticagrelor Compared with Clopidogrel in Patients with Acute Coronary Syndrome from Vietnamese Healthcare Payers' Perspective

INTRODUCTION

The PLATelet inhibition and patient Outcomes (PLATO) trial (NCT00391872) demonstrated that ticagrelor compared to clopidogrel significantly reduced the rate of death from cardiovascular causes, myocardial infarction or stroke in patients with acute coronary syndrome (ACS). The aim of this study is to analyze the long-term cost-effectiveness of ticagrelor compared to clopidogrel in ACS patients from a Vietnamese healthcare payers' perspective.

METHODS

A two-part cost-effectiveness model was developed to estimate long-term costs and quality-adjusted life-years (QALY). Cardiovascular event rates, hospital bed days, interventions, investigations, study drug utilization and EuroQol 5 Dimension (EQ-5D) data were derived from the PLATO trial. Unit costs of medical services were derived from the Vietnamese governmental price list, and drug costs were based on the weighted average price from the Vietnamese social security report (in VND; 10.000 VND = 0.405 USD). An annual discount rate of 3% was used. Probabilistic and deterministic sensitivity analyses were conducted to evaluate uncertainty of the results.

RESULTS

Ticagrelor was associated with an incremental cost of VND 5.34 million (USD 216.49) and a QALY gain of 0.11. This resulted in a cost per QALY gained of VND 49.58 million (USD 2009.96) from the Vietnamese healthcare payers' perspective. Probabilistic sensitivity analysis indicates that ticagrelor has 59% probability of being cost-effective compared with clopidogrel when using a willingness-to-pay threshold of one gross domestic products (GDP) per capita. Deterministic sensitivity analysis using clinical outcomes from the Asian sub-population of PLATO resulted in a cost per QALY of VND 42.25 million (USD 1712.80).

CONCLUSION

Ticagrelor can be considered a cost-effective treatment for ACS compared with clopidogrel from a Vietnamese healthcare payers' perspective.

Cost-effectiveness of ticagrelor in patients with type 2 diabetes and coronary artery disease with a history of PCI: an economic evaluation of THEMIS-PCI using a Swedish healthcare perpective

Background

The Effect of Ticagrelor on Health Outcomes in diabEtes Mellitus patients Intervention Study (THEMIS) evaluated ticagrelor compared to placebo for the prevention of myocardial infarction (MI), stroke and cardiovascular (CV) death in 19 220 patients with type 2 diabetes (T2DM) and stable coronary artery disease (CAD) with no prior myocardial infarction (MI) or stroke. THEMIS-PCI was a pre-specified subgroup of 11 154 patients who had a history of percutaneous coronary intervention (PCI) when entering the study. In THEMIS, ticagrelor reduced CV death, MI or stroke, although with an increase in major bleeding compared to aspirin alone, and there was a significant interaction between a prior history of PCI and the net benefit of ticagrelor. In the THEMIS-PCI population, ticagrelor plus aspirin provided a favourable net clinical benefit with a significant 15% reduction in all-cause death, MI, stroke, fatal bleed, or intracranial haemorrhage.

Objective

The objective of this analysis was to estimate the cost-effectiveness of ticagrelor for the prevention of CV events based on the results of the THEMIS-PCI population using a lifetime horizon from a Swedish healthcare perspective.

Methods

A lifetime Markov state transition model was developed with health states aligned to the THEMIS trial endpoints. Health state transitions were informed by parametric survival equations fitted to patient level data from THEMIS-PCI population. Treatment discontinuation rates were informed by the THEMIS-PCI population, with all patients assumed to discontinue treatment with ticagrelor after four years. The incidence of bleeding and dyspnoea were modelled as adverse events. Costs (2019 Euros) and utility data were derived from the published literature and the THEMIS-PCI population, respectively, and discounted at 3.0% annually. Probabilistic (PSA) and deterministic sensitivity analysis (DSA) were conducted to quantify uncertainty of key input parameters.

Results

Treatment with ticagrelor plus aspirin over four years resulted in estimated Quality Adjusted Life Year (QALY) gains of 0.09 at an incremental cost of €1,891 compared to aspirin alone. The estimated incremental cost-effectiveness ratio (ICER) was €19,959/QALY. PSA indicated that ticagrelor was cost-effective in 93% of simulations using a willingness-to-pay threshold of €47,000/QALY and DSA showed that cost-effectiveness was robust to changes in key input parameters (ICER range: €16,504 to €25,012/QALY).

Conclusion

Based on the results of the THEMIS trial, dual antiplatelet therapy with ticagrelor plus aspirin is likely to be a cost-effective treatment compared with aspirin alone for the prevention of CV events in patients with T2DM and CAD with a history of PCI.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): AstraZeneca

P5471Baseline characteristics, healthcare resource use and clinical outcomes of stable post-myocardial infarction patients with diabetes: insights from the global prospective TIGRIS study

Background

There is a growing prevalence of diabetes worldwide in patients in the general population, including those with prior myocardial infarction (MI).

Purpose

To describe the characteristics, health status, resource utilization and clinical adverse events of stable post-MI patients with diabetes.

Methods

The long-Term rIsk, clinical manaGement and healthcare Resource utilization of stable coronary artery dISease (TIGRIS) prospective observational study (NCT01866904) obtained data from 8985 stable patients 1–3 years post-MI from 369 centres in 25 countries, who provided diabetes status (no, yes, insulin-treated) and follow-up. Diabetes status, other patient characteristics, medications, medical history and healthcare resource utilization were recorded at enrolment. Health status was assessed at enrolment, 1 and 2 years by EQ-5D-3L and converted to an EQ-5D score. Deaths, cardiovascular (CV) events, bleeding events and related hospitalizations were recorded during 2 years of follow-up.

Results

Diabetes mellitus (DM) was prevalent at enrolment in 2966 (33%) patients of whom 872 (29%) were insulin-treated. Compared to patients without DM, those with DM had a higher mean body mass index (28.2 vs 26.6kg/m2) and heart rate (71 vs 67bpm), were more likely to have had ≥2 prior MIs (12% vs 10%), chronic kidney disease (10% vs 6%), peripheral artery disease (10% vs 5%), heart failure (15% vs 10%), anaemia (4% vs 2%), angina (12% vs 9%), stroke (6% vs 4%) and chronic obstructive pulmonary disease (9% vs 7%). Patients with DM reported more problems for each domain of the EQ-5D (mobility, self-care, usual activities, pain/discomfort, and anxiety/depression), which resulted in a lower mean EQ-5D utility score at enrolment (0.83±0.22 for no-diabetes vs 0.86±0.19 for diabetes). Moreover, they also had higher CV hospitalization rates in the 6 months prior to enrolment (6.4% vs 5%). All these measures were more marked in insulin-dependent diabetics. The incidences of all-cause death, CV death and the composite of CV death, MI and stroke were all significantly higher in patients with DM, especially those on insulin (see Figure). For CV death, MI and stroke the 2-year risk ratios, compared to patients without DM, were 2.64 (P<0.001) and 1.48 (P<0.001) respectively for those with insulin-treated DM and non-insulin treated.

Figure 1

Conclusions

Within a global population of stable post-MI patients, those with DM (especially those on insulin) have poorer health status and EQ-5D utility score, higher hospitalization rates and worse clinical outcomes compared with those without DM. Thus, in cardiac clinics worldwide, patients with DM require particularly close attention.

Acknowledgement/Funding

The study was funded by AstraZeneca

Abstract 291: Abstract Title: Assessment of The High risk and unmEt Need in Patients with CAD and Type 2 Diabetes (ATHENA): US Healthcare Resource Use and Cost in a Commercially-Insured Population

Background: THEMIS is a large randomized controlled trial (NCT01991795) comparing the effect of ticagrelor vs placebo (both with background acetylsalicylic acid) for the prevention of major cardiovascular (CV) events in patients with coronary artery disease (CAD) and type 2 diabetes (T2D) with no prior myocardial infarction (MI) or stroke. The current study evaluated healthcare resource utilization (HCRU) and cost in patients similar to those eligible for enrollment in THEMIS (THEMIS-like) and in a broader population (T2D-CAD).

Methods: This retrospective, observational study included patients, > 50 years old, with pharmacologically treated T2D and no prior MI or stroke collected from the Optum Research Database including Medicare Advantage Part D coverage between January 1, 2007 and December 31, 2017. Both cohorts were followed until disenrollment or end of the study period. The THEMIS-like cohort included patients with evidence of CAD including percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG), or an angina diagnosis. In addition to CAD as above, the broader T2D-CAD cohort included use of prescription antiplatelet therapy. Selected HCRU (heart failure hospitalizations [hHF], nontraumatic bleeding hospitalizations or ED visits, medication use), annualized costs (all-cause and CV-related total, medical, and pharmacy), and secondary prevention medication (antiplatelets, statins, ACE inhibitors, ARBs, and beta-blockers) persistence were analyzed.

Results: The T2D-CAD (N=203,916) and THEMIS-like (N=127,125) cohorts accounted for 3.5% and 2.2% of the total T2D population, respectively. Mean + SD ages were 68 + 9 vs 67 + 9 years and 57% vs 56% were men, respectively. Mean annual all-cause total costs for the THEMIS-like and T2D-CAD cohorts were $43,332 and $36,254, and pharmacy costs accounted for 15.3% and 19.2% of total cost, respectively. CV-related costs accounted for 38.2% of all-cause costs in the THEMIS-like cohort, and 29.1% in T2D-CAD cohort, respectively. Mean all-cause pharmacy and CV-related pharmacy costs were $6,668 and $497 for the THEMIS-like cohort and $6,985 and $739 for the T2D-CAD cohort, respectively. Medication persistence was between 55% and 61% for all medication classes for both cohorts. At least one hHF was experienced by 13.3% of patients in the THEMIS-like cohort and by 10.3% of patients in the T2D-CAD cohort. Bleeding event rates were 0.35 and 0.38 per 100 person-years in the THEMIS-like and T2D-CAD cohorts, respectively.

Conclusion: Patients in a US commercially-insured population similar to those enrolled in THEMIS incurred high cost of care, which was largely attributable to CV-related causes. Nearly 1 in 7 THEMIS-like patients experienced hHF, and bleeding incidence was low. These findings identify a unique patient population that may benefit from better preventive measures.

Lifetime cost-effectiveness analysis of ticagrelor in patients with acute coronary syndromes based on the PLATO trial: a Singapore healthcare perspective

INTRODUCTION

Ticagrelor is a novel antiplatelet drug developed to reduce atherothrombosis. The PLATO trial compared ticagrelor and aspirin to clopidogrel and aspirin in patients with acute coronary syndromes (ACS). Ticagrelor was found to be superior in the primary composite endpoint of cardiovascular death, myocardial infarction or stroke, without increasing major bleeding events. The current study estimates the lifetime cost-effectiveness of ticagrelor relative to generic clopidogrel from a Singapore public healthcare perspective.

METHODS

This study used a two-part cost-effectiveness model. The first part was a 12-month decision tree (using PLATO trial data) to estimate the rates of major cardiovascular events, healthcare costs and health-related quality of life. The second part was a Markov model estimating lifetime quality-adjusted survival and costs conditional on events during the initial 12 months. Daily drug costs applied were SGD 1.05 (generic clopidogrel) and SGD 6.00 (ticagrelor). Cost per quality-adjusted life years (QALY) was estimated from a Singapore public healthcare perspective using life tables and short-term costs from Singapore, and long-term costs from South Korea. Deterministic and probabilistic sensitivity analyses were performed.

RESULTS

Ticagrelor was associated with a lifetime QALY gain of 0.13, primarily driven by lower mortality. The resulting incremental cost per QALY gained was SGD 10,136.00. Probabilistic sensitivity analysis indicated that ticagrelor had a > 99% probability of being cost-effective, given the lower recommended WHO willingness-to-pay threshold of one GDP/capita per QALY.

CONCLUSION

Based on PLATO trial data, one-year treatment with ticagrelor versus generic clopidogrel in patients with ACS, relative to WHO reference standards, is cost-effective from a Singapore public healthcare perspective.