Cost-effectiveness of prasugrel in a US managed care population

Figures & data

Table 1.  Monthly CV-related and bleeding-related event rates after an ACS episode with PCI, per 100 patients13,14.

Population sub-group	Month 1		Months 2–15
	Clopidogrel-based therapy event rate (95% CIs)	Prasugrel-based rherapy relative risk (95% CIs)	Clopidogrel-based therapy monthly event rate (95% CIs)	Prasugrel-based therapy relative risk (95% CIs)
Hospitalization events
Repeat PCI, with MI	1.78 (1.46, 2.10)	0.29 (0.14, 0.61)	0.29 (0.16, 0.42)	0.74 (0.53, 1.04)
Repeat PCI, without MI	3.80 (3.34, 4.26)	0.92 (0.70, 1.21)	0.59 (0.40, 0.77)	0.80 (0.69, 0.93)
CABG, with MI	0.13 (0.05, 0.22)	1.00 (1.00, 1.00)	0.03 (0.00, 0.07)	1.00 (1.00, 1.00)
CABG, without MI	0.48 (0.31, 0.64)	0.71 (0.37, 1.38)	0.13 (0.04, 0.21)	1.06 (0.71, 1.58)
MI, no PCI or CABG	0.21 (0.10, 0.32)	1.07 (0.50, 2.27)	0.05 (0.00, 0.10)	0.57 (0.36, 0.91)
Stroke	0.16 (0.07, 0.26)	0.40 (0.12, 1.27)	0.03 (0.00, 0.08)	0.84 (0.51, 1.39)
Angina (stable and unstable)	0.91 (0.68, 1.14)	1.12 (0.64, 1.97)	0.25 (0.13, 0.37)	1.16 (0.84, 1.61)
Other CV^a
Arrhythmia	0.16 (0.07, 0.26)	1.35 (0.62, 2.93)	0.06 (0.05, 0.08)	1.37 (0.98, 1.92)
Heart failure/shock	0.28 (0.16, 0.41)	0.93 (0.49, 1.77)	0.07 (0.05, 0.09)	1.34 (0.98, 1.83)
All others	2.80 (2.40, 3.19)	1.12 (0.92, 1.36)	0.55 (0.51, 0.60)	1.14 (1.02, 1.28)
Bleeding^b	0.63 (0.35, 0.94)	1.04 (0.57, 1.89)	0.11 (0.08, 0.15)	1.61 (1.15, 2.26)
ER visits^c
CV: no bleeding^d	1.51 (1.22, 1.80)	0.77 (0.68, 0.88)	0.44 (0.28, 0.60)	0.88 (0.81, 0.96)
Bleeding^e	0.07 (0.01, 0.14)	1.04 (0.57, 1.89)	0.02 (0.00, 0.05)	1.61 (1.15, 2.26)

ACS, acute coronary syndrome; CABG, coronary artery bypass graft; CI, confidence interval; CMS-DRG, Centers for Medicare and Medicaid Services Diagnosis-Related Group; CV, cardiovascular; ER, emergency department; MI, myocardial infarction; MS-DRG, Medicare Severity Diagnosis-Related Group; PCI, percutaneous coronary intervention.

^aUsed in an alternative scenario. The ‘other CV’ event group is considered to be any hospitalization for arrhythmia [CMS-DRG (138,139) or MS-DRG (308, 310)], heart failure/shock [CMS-DRG (127) or MS-DRG (292, 293)], or all others including cerebrovascular disorders, pulmonary embolism or edema, circulatory disorders (except acute MI), peripheral vascular disorders, atherosclerosis, cardiac disorders, and syncope [CMS-DRG (016, 017, 078, 087, 088, 117, 124, 125, 129, 130, 131, 132, 133, 141, 142, 144, 145, 479, 515, 533, 534, 535, 536, 551, 552, 553, 554) or MS-DRG (176, 189, 190, 192, 223, 225, 227, 243, 253, 254, 286, 287, 303, 312, 314, 315)].

^bThe rates for bleeding events requiring hospitalization were taken from the TRITON-TIMI 38 eight-country economic cohort data.

^cER visits that involve bleeding with or without a CV-related problem.

^dCV: no bleeding relative risks for prasugrel-based therapy were derived by calculating a weighted average risk from all CV events.

^eBleeding with or without CV relative risks for prasugrel-based therapy were equal to the relative risk for a bleeding event that required hospitalization.

Table 2.  Base-case scenario for the total MCO population for the 15-month time horizon, per 100 patients.

Outputs	Clopidogrel-based therapy	Prasugrel-based therapy	Difference: prasugrel-based therapy – clopidogrel-based therapy
Costs
Total	$3,811,603	$3,714,513	−$97,090
Initial hospitalization	$3,040,903	$3,042,111	$1,207
Thienopyridine costs	$170,702	$170,386	−$315
ER visit costs^a	$6,947	$6,054	−$893
CV: no bleeding	$6,758	$5,781	−$977
Bleeding with or without CV	$188	$273	$84
Rehospitalization costs	$593,052	$495,962	−$97,089
Health outcomes
Number of CV and bleeding events per 100 patients^b	32.5	28.8	−3.7
Rehospitalizations	25.5	22.7	−2.8
Repeat PCI, with MI	5.2	3.0	−2.2
Repeat PCI, no MI	10.7	9.0	−1.7
CABG, with MI	0.5	0.5	0.0
CABG. no MI	2.0	1.9	−0.0
MI, no PCI or CABG	0.8	0.5	−0.2
Stroke	0.6	0.4	−0.2
Angina	3.9	4.4	0.6
Bleeding	2.0	2.8	0.8
ER visits	6.9	6.1	−0.9
CV: No bleeding	6.7	5.7	−1.0
Bleeding	0.3	0.4	0.1

CABG, coronary artery bypass graft; CV, cardiovascular; ER, emergency department; MCO, managed care organization; MI, myocardial infarction; PCI, percutaneous coronary intervention.

^aER visits not resulting in admission to the hospital.

^bThe number of CV and bleeding events is the sum of the number of ER visits and the number of rehospitalizations.

Table 3.  Scenarios for alternative MCO sub-populations and time horizons, per 100 patients.

MCO sub-population	Difference in total costs: prasugrel-based therapy – clopidogrel-based therapy	Difference in CV and bleeding events: prasugrel-based therapy – clopidogrel-based therapy^a	Difference in rehospitalizations: prasugrel-based therapy – clopidogrel-based therapy
Total population (base case) (n = 6687)	−$97,090	−3.7	−2.8
Alternative patient sub-populations
Males (n = 5174)	−$96,046	−3.7	−2.8
Females (n = 1513)	−$100,754	−3.8	−2.8
<65 years (n = 5587)	−$101,464	−3.8	−2.9
65–74 years (n = 803)	−$68,516	−2.6	−2.2
≥75 years (n = 297)	−$89,766	−3.3	−2.7
With diabetes (n = 1777)	−$112,835	−4.5	−3.5
Without diabetes (n = 4910)	−$91,359	−3.4	−2.6
STEMI (n = 3276)	−$107,620	−4.2	−3.3
NSTEMI/UA (n = 3411)	−$87,008	−3.1	−2.4
DES (n = 5534)	−$91,002	−3.5	−2.6
BMS or no stent (n = 1153)	−$126,223	−4.4	−3.9
Alternative time horizons
30 days	−$48,437	−2.0	−1.7
1 year	−$87,953	−3.4	−2.6
Alternative TRITON-TIMI 38 cohorts
US cohort	−$112,548	−3.7	−2.8
North American cohort	−$112,317	−3.6	−2.8
Hypothetical generic clopidogrel prices
Clopidogrel at $3 per day less than prasugrel	−$175	−3.7	−2.8
Clopidogrel at $4 per day less than prasugrel	$32,022	−3.7	−2.8
Inclusion of other CV events
Other CV events	−$59,625	−1.4	−0.5

BMS, bare-metal stent; CV, cardiovascular; DES, drug-eluting stent; ER, emergency department; MCO, managed care organization; NSTEMI, non-ST-elevation myocardial infarction; STEMI, ST-elevation myocardial infarction; UA, unstable angina; US, United States.

^aThe number of CV and bleeding events are composed of the number of ER visits and the number of rehospitalizations.

Figure 1.  One-way sensitivity analysis results per 100 patients: Tornado diagram. CABG, coronary artery bypass graft; MI, myocardial infarction; PCI, percutaneous coronary intervention; RR, relative risk.

Figure 2.  Probabilistic sensitivity analysis: acceptability curve.

Eli Lilly data on file. Eli Lilly’s analysis of i3 InVision Data Mart data from 2006 to mid-2008. October 2009. Available at: http://www.i3global.com

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Daiichi-Sankyo, Incorporated/Lilly Research Laboratories data on file. TRITON-TIMI 38 eight-country economic cohort data, Indianopolis, Indiana

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