Prasugrel vs clopidogrel in patients with acute coronary syndrome undergoing percutaneous coronary intervention: a model-based cost-effectiveness analysis for Germany, Sweden, the Netherlands, and Turkey

Figures & data

Table 1.  Summary of key base-case model inputs.

Input	Value		Source
General model data
RRs for post-trial all-cause mortality^a
UA/NSTEMI	1.55 (1.31–1.84)		Allen et al.32
STEMI	1.84 (1.52–2.20)		Allen et al.32
recurrent NSTEMI	2.93 (2.34–3.66)		Mueller et al.33
recurrent STEMI	3.48 (2.77–4.37)		Mueller et al.33
stroke	2.39 (1.44–3.97)		Taneja et al.34
HRQoL decrements:
ACS	0.0409 (±0.0002)		Sullivan et al.36
stroke	0.0524 (±0.0002)		Sullivan et al.36
TIMI major bleed^b	25% decrement to population norms over 14 days		Assumption based on Wechowski et al.37
Country-specific data	Germany	Sweden	Netherlands	Turkey
Discount rates for outcomes	3%45	3%46	1.5%47	3%48
Discount rates for costs	3%	3%	4.0%	3%
Clopidogrel^c	€0.64	€0.08	€0.06	€1.02
Prasugrel	€2.92	€1.50	€1.58	€2.03
Aspirin (low dose)	€0.04	€0.08	€0.04	€0.04
Clopidogrel re-hospitalization^d	€4463	€5945	€3336	€2068
Prasugrel re-hospitalization^d	€4259	€5385	€3164	€2105

HR, hazard ratio; RR, relative risk.

^aIn addition to cited source relative risk is derived using Rosengren et al.30

^bPopulation norms according to Kind et al.35

^cDrug cost sources: Germany: Lauer Taxe; Sweden: Public Prices, TLV, August 2011; Netherlands: Taxe, Z-Index, August 2011; Turkey: Ministry of Health General Directorate of Pharmaceuticals and Pharmacy Price List. German drug prices paid by sickness funds, excludes patient co-payment and mandatory rebates (manufacturer and pharmacy).

^dCalculated from local DRGs: Germany: G-DRG-System 2009. Institut für das Entgeltsystem im Krankenhaus 2009, Sweden: Price list Region skåne-Skånes University Hospital; Nord DRG classics, August 18, 2011, The Netherlands: http://ctg.bit-ic.nl/Nzatarieven/top.do; Price level June 2009, Turkey: DRG costs from 20 hospitals in Turkey Price level 2008. Purchasing power parities (December 2011), Germany 1.00, Sweden 12.772, Netherlands 1.188, Turkey 1.368 [http://stats.oecd.org/Index.aspx?DataSetCode = SHA accessed 23 January 2012].

Figure 1.  Model pathways for the cost-effectiveness model.

Table 2.  Cost-effectiveness results for overall licensed population and specific sub-groups (event rates at 12 months).

	Licensed population		UA-NSTEMI		STEMI		ACS diabetes		Core cohort
	(n = 13,090)		(n = 9669)		(n = 3421)		(n = 2947)		(n = 10,804)
	Clopidogrel	Prasugrel	Clopidogrel	Prasugrel	Clopidogrel	Prasugrel	Clopidogrel	Prasugrel	Clopidogrel	Prasugrel
Cardiovascular death	2.05%	1.76%	1.80%	1.66%	2.76%	2.05%	3.59%	2.73%	1.57%	1.36%
Myocardial infarction	8.49%	6.43%	8.60%	6.61%	8.17%	5.91%	10.64%	6.72%	8.15%	6.21%
Stroke	0.74%	0.69%	0.72%	0.54%	0.79%	1.12%	1.23%	1.01%	0.64%	0.58%
Total combined end-point	11.28%	8.87%	11.13%	8.80%	11.71%	9.08%	15.46%	10.46%	10.36%	8.14%
TIMI major bleed	1.71%	2.30%	1.49%	2.18%	2.32%	2.64%	2.21%	2.50%	1.50%	1.99%
TIMI minor bleed	1.93%	2.51%	1.69%	2.40%	2.61%	2.82%	2.70%	2.93%	1.47%	1.96%
Total bleed	3.64%	4.81%	3.18%	4.58%	4.93%	5.46%	4.91%	5.42%	2.97%	3.95%
Germany
Drug cost	226	1044	227	1045	225	1042	224	1037	227	1050
Hospitalization costs ≤12 months	1797	1662	1811	1676	1755	1622	1998	1761	1761	1630
Hospitalization costs >12 months	17,919	18,019	17,952	18,029	17,824	17,989	16,773	17,019	19,440	19,540
Total costs	19,942	20,725	19,990	20,751	19,804	20,652	18,995	19,817	21,428	22,220
QALYs	10.657	10.712	10.661	10.702	10.647	10.740	9.972	10.109	11.524	11.579
Incremental cost per QALY (€)		14,350		18,530		9131		6025		14,487
Sweden
Drug cost	28	535	28	536	28	534	28	531	28	538
Hospitalization costs ≤12 months	2395	2102	2415	2120	2339	2052	2664	2228	2347	2063
Hospitalization costs >12 months	24,580	24,708	24,578	24,674	24,587	24,803	22,941	23,261	26,752	26,880
Total costs	27,003	27,345	27,020	27,330	26,954	27,388	25,633	26,021	29,128	29,481
QALYs	10.945	10.997	10.930	10.968	10.988	11.080	10.214	10.347	11.870	11.923
Incremental cost per QALY (€)		6520		8016		4738		2910		6711
Netherlands
Drug cost	18	564	18	564	18	562	18	559	18	566
Hospitalization costs ≤12 months	1338	1230	1349	1240	1307	1200	1488	1303	1311	1206
Hospitalization costs >12 months	12,290	12,353	12,300	12,348	12,262	12,370	11,543	11,703	13,297	13,359
Total costs	13,646	14,147	13,667	14,152	13,587	14,132	13,049	13,566	14,626	15,132
QALYs	12.919	12.987	12.907	12.959	12.952	13.065	11.988	12.156	14.053	14.122
Incremental cost per QALY (€)		7369		9378		4788		3080		7342
Turkey
Drug cost	361	725	361	726	359	723	356	720	363	729
Hospitalization costs ≤12 months	350	345	353	348	342	337	389	365	343	339
Hospitalization costs >12 months	3079	3097	3083	3097	3068	3098	2845	2890	3368	3387
Total costs	3789	4167	3796	4171	3769	4158	3591	3975	4074	4455
QALYs	9.521	9.573	9.518	9.558	9.531	9.616	8.810	8.937	10.366	10.419
Incremental cost per QALY (€)		7294		9371		4552		3036		7207

Figure 2.  Cost-effectiveness acceptability curves showing the probability of prasugrel being cost-effective (compared to clopidogrel) for a range of cost-effectiveness thresholds. This is shown for the patient profile with median cost-effectiveness in the overall licensed ACS population (based on net health benefit at €30,000 per QALY).

Table 3.  Cost-effectiveness sensitivity analyses for overall licensed population.

	Germany			Sweden			Netherlands			Turkey
	Cost	QALY	ICER (€)	Cost	QALY	ICER (€)	Cost	QALY	ICER (€)	Cost	QALY	ICER (€)
base case	783	0.055	14,350	342	0.052	6520	501	0.068	7369	378	0.052	7294
0% discounting	859	0.089	9607	430	0.086	4992	568	0.088	6442	394	0.082	4824
5% discounting	752	0.041	18,225	308	0.040	7768	490	0.040	12,122	370	0.040	9261
4 × bleed HRQoL decrement	783	0.054	14,379	342	0.052	6534	501	0.068	7381	378	0.052	7309
½ × MI/stroke HRQoL decrement	783	0.055	14,313	342	0.053	6503	501	0.068	7350	378	0.052	7275
2 × MI/stroke HRQoL decrement	783	0.054	14,425	342	0.052	6555	501	0.068	7406	378	0.052	7332
½ × MI/stroke mortality effect	763	0.044	17,497	316	0.042	7522	488	0.054	8947	374	0.042	9017
2 × MI/stroke mortality effect	801	0.064	12,498	366	0.062	5894	512	0.079	6509	381	0.060	6382
zero hospital costs	818	0.055	14,994	507	0.052	9656	546	0.068	8029	364	0.052	7032
½ × rehospitalization costs	801	0.055	14,672	425	0.052	8088	523	0.068	7699	371	0.052	7163
2 × rehospitalization costs	748	0.055	13,706	178	0.052	3385	456	0.068	6708	392	0.052	7556
clopidogrel loading adjustment	766	0.042	18,181	321	0.041	7908	491	0.052	9375	375	0.040	9399
clopidogrel drug cost set at zero	1009	0.055	18,494	371	0.052	7058	519	0.068	7634	739	0.052	14,251

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