Cost-effectiveness analysis of anticoagulation strategies in non-ST-elevation acute coronary syndromes
Carleton B Maxwell1, David A Holdford, Michael A Crouch
1Jackson Madison County General Hospital, Jackson, TN, USA.
Insights
Bivalirudin is the most cost-effective anticoagulant for high-risk non-ST-elevation acute coronary syndrome (NSTE-ACS) patients undergoing invasive procedures. Fondaparinux is preferred for conservative management strategies.
Area of Science:
- Cardiology
- Pharmacoeconomics
- Health Services Research
Background:
- Studies compare unfractionated heparin (UFH), enoxaparin, fondaparinux, and bivalirudin for non-ST-elevation acute coronary syndrome (NSTE-ACS).
- The cost-effectiveness of these anticoagulant regimens in NSTE-ACS remains uncertain.
Purpose of the Study:
- To conduct a cost-effectiveness analysis comparing four anticoagulant regimens in NSTE-ACS patients.
- Evaluate the economic impact of different antithrombotic strategies.
Main Methods:
- Decision analysis from a healthcare provider perspective using data from SYNERGY, OASIS-5, and ACUITY trials.
- A decision tree model assessed UFH with eptifibatide, enoxaparin with eptifibatide, bivalirudin alone, and fondaparinux with eptifibatide.
- Calculated complication probabilities and assigned costs, including drug acquisition and red blood cell infusions.
Main Results:
- Bivalirudin monotherapy was the least costly ($1131) and dominated enoxaparin/eptifibatide ($1609) and UFH/eptifibatide ($1739).
- Fondaparinux/eptifibatide ($1184) was more effective than bivalirudin, with an incremental cost of $2569 per additional complication-free patient.
- Sensitivity analyses indicated cost-effectiveness is sensitive to drug acquisition costs and complication rates; bivalirudin lost cost-effectiveness when multiple vials were needed.
Conclusions:
- Bivalirudin is the least costly option for moderate- to high-risk NSTE-ACS patients managed invasively, aligning with ACUITY trial findings.
- Fondaparinux is the preferred agent for patients managed conservatively.
- Optimal anticoagulant choice depends on the management strategy and specific patient risk factors.
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.
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