THE ECONOMICS OF ADJUNCTIVE THERAPIES IN CORONARY ANGIOPLASTY: DRUGS, DEVICES, OR BOTH?

Main Article Content

Paul I. Oh
Eric A. Cohen
Nicole Mittmann
Soo Jin Seung

Keywords

abciximab, cost-effectiveness, percutaneous coronary intervention

Abstract

Background


Abciximab reduces the number of  ischemic events in patients undergoing angioplasty compared to standard therapy. Coronary stenting reduces the need for repeat procedures. Abciximab or stents individually are considered cost effective interventions. There is a need to quantify the economic value of the combination of abciximab and stenting over stenting alone.


 Methods


A decision analytic model was developed incorporating the outcomes from the EPISTENT study. Costs from Canadian sources for hospitalization, procedures and medications were used. Life expectancy was estimated using a Markov model. Total expected costs and outcomes of the abciximab and stent vs. stent alone were compared in an incremental analysis. The perspective of the analysis was a Canadian teaching hospital.


 Results


The acquisition cost for abciximab was partially offset by reduced costs for managing clinical events resulting in a net incremental cost of $1,076 per patient over one year ($8,617 combination vs. $7,541 stent alone). This added cost was accompanied by a reduction in large MI or death by an absolute rate of 5.7% at one year (5.3% combination vs. 11.0% stent alone), yielding an incremental cost-effectiveness ratio of $18,877 per death or large MI averted. The long-term survival gain was 0.15 to 0.37 years yielding an attractive incremental cost effectiveness ratio of $2,832 to $7,173 per life year gained.


 Conclusions


The combination of abciximab and stenting versus stenting alone provides improved clinical outcomes at a very reasonable cost from the Canadian hospital perspective

Abstract 83 | PDF Downloads 40

References

1. Lefkovits, J, Plow EF, and Topol EJ, Platelet glycoprotein IIb/IIIa receptors in cardiovascular medicine. N Engl J Med 1995;332(23):1553-9.
2. Topol, EJ, et al., Randomised trial of coronary intervention with antibody against platelet IIb/IIIa integrin for reduction of clinical restenosis: results at six months. The EPIC Investigators. Lancet 1994;343(8902):881-6.
3. The EPIC Investigators. Use of a monoclonal antibody directed against the platelet glycoprotein IIb/IIIa receptor in high-risk coronary angioplasty.
The EPIC Investigation. N Engl J Med 1994;330(14):956-61.
4. The EPILOG Investigators. Platelet glycoprotein IIb/IIIa receptor blockade and low-dose heparin during percutaneous coronary revascularization.
The EPILOG Investigators. N Engl J Med, 1997; 336(24):1689-96.
5. Canadian Cardiac Network, CCN-Expert Panel on Coronary Stenting (www.ccn.on.ca). 1999.
6. Mark, DB, et al., Economic assessment of platelet glycoprotein IIb/IIIa inhibition for prevention of ischemic complications of high-risk coronary angioplasty. EPIC Investigators. Circulation, 1996;94(4):629-35.
7. Cohen, DJ, et al., Evaluating the potential cost- effectiveness of stenting as a treatment for symptomatic single-vessel coronary disease. Use of a decision-analytic model. Circulation, 1994;89(4):1859-74.
8. Topol, E, et al., Outcomes at 1 year and economic implications of platelet glycoprotein IIb/IIIa blockade in patients undergoing coronary stenting: results from a multicentre randomised trial. Lancet, 1999;354:2019-2024.
9. The EPISTENT Investigators, Randomised placebo-controlled and balloon-angioplast- controlled trial to assess safety of coronary stenting with use of platelet glycoprotein-IIb/IIIa blockade. Lancet, 1998;352:87-92.
10. Califf, RM, et al., Myonecrosis after revascularization procedures. J Am Coll Cardiol,1998;31(2): 241-51.
11. Topol, EJ, et al., Long-term protection from myocardial ischemic events in a randomized trial of brief integrin beta3 blockade with percutaneous coronary intervention. EPIC Investigator Group. Evaluation of Platelet IIb/IIIa Inhibition for Prevention of Ischemic Complication. JAMA, 1997;278(6):479-84.
12. Statistics Canada, Life tables. 1995.
13. Topol, E, et al., Multi-year follow-up of abciximab therapy in three randomized, placebo controlled trials of percutaneous coronary revascularization. American Journal of Medicine, 2002;113:1-6.
14. Laupacis, A., et al., How attractive does a new technology have to be to warrant adoption and utilization? Tentative guidelines for using clinical and economic evaluations. Can Med Assoc J, 1992;146(4):473-81.
15. Lincoff, AM, et al., Evidence for prevention of death and myocardial infarction with platelet membrane glycoprotein IIb/IIIa receptor blockade by abciximab (c7E3 Fab) among patients with unstable angina undergoing percutaneous coronary revascularization. EPIC Investigators. Evaluation of 7E3 in Preventing Ischemic Complications. J Am Coll Cardiol, 1997;30(1):149-56.
16. Lucore, C, et al., Impact of abciximab and coronary stenting on outcomes and costs of percutaneous coronary interventions in a community hospital. Coronary Artery Disease, 2001;12:135-142.
17. Aristides, M, et al., Effectiveness and cost effectiveness of single bolus treatment with abciximab (Reo Pro) in preventing restenosis following percutaneous transluminal coronary angioplasty in high risk patients. Heart, 1998;79(1):12-7.
18. ESPRIT Investigators, Novel dosing regimen of eptifibatide in planned coronary stent implantation (ESPRIT): a randomised, placebo-controlled trial. Lancet, 2000;356(9247):2037-44.
19. The PRICE Investigators, Comparative 30-day economic and clinical outcomes of platelet glycoprotein IIb/IIIa inhibitor use during elective percutaneous coronary intervention: Prairie ReoPro versus Integrilin Cost Evaluation (PRICE) Trial. American Heart Journal, 2001;141(3):402-409.
20. Juergens, C, et al., A mutlicenter study of the tolerability of tirofiban versus placebo in patients undergoing planned intracoronary stent placement. Clinical Therapeutics, 2002;24(8):1332-1344.
21. Topol, E, et al., Comparison of two platlet glycoprotein IIb/IIIA inhibitors, tirofiban and abciximab, for the prevention of ischemic events with percutaneous coronary revascularization. NEJM, 2001;344(25):1888-1894.
22. Moliterno, DJ, et al., Outcomes at 6 months for the direct comparison of tirofiban and abciximab during percutaneous coronary revascularisation with stent placement: the TARGET follow-up study. Lancet, 2002;360(9330):355-60.
23. Cho, L, et al., Optimizing percutaneous coronary revascularization in diabetic women: analysis from the EPISTENT trial. Journal of Women's Health and Gender Based Medicine, 2000;9(7):741-746.
24. Marso, SP, et al., Optimizing the percutaneous interventional outcomes for patients with diabetes mellitus: results of the EPISTENT (Evaluation of platelet IIb/IIIa inhibitor for stenting trial) diabetic substudy. Circulation, 1999;100(25):2477-84.
25. Kong, TQ, et al., Prognostic implication of creatine kinase elevation following elective coronary artery interventions. JAMA,
1997;277(6):461-6.
26. Abdelmeguid, AE, et al., Significance of mild transient release of creatine kinase-MB fraction after percutaneous coronary interventions. Circulation, 1996;94(7):1528-36.
27. Zwart-van Rijkom, J, et al., Costs and effects of combining stenting and abciximab (RePro) in daily practice. International Journal of Cardiology, 2001;77:299-303.
28. Islam, M, et al., Effect of abciximab on angiographic complications during percutaneous coronary stenting in the evaluation of platelet IIb/IIIa inhibition in stenting trial (EPISTENT). American Journal of Cardiology, 2002;90:916-921.

Most read articles by the same author(s)