Long-term cost-effectiveness of clopidogrel in STEMI patients.

BACKGROUND: The COMMIT trial demonstrated that clopidogrel produced a 9% relative reduction in death, reinfarction or stroke (9.2% vs. 10.1%, 95% CI: 0.86-0.97) in ST-elevated myocardial infarction (STEMI) patients. METHODS: Between 08/1999 and 05/2005, 45,852 STEMI patients were randomized to clopidogrel (n=22,961) or matching placebo (n=22,891) in addition to aspirin. The rate of initial hospitalizations for death, non-fatal myocardial infarction with/without major complications and PCI within 28 days was calculated based on the COMMIT clinical paper. Three CURE papers, concerning non-STEMI patients, were used to estimate the event rates between 29 days and 1 year. Hospitalizations were assigned a diagnosis-related group (DRG). Costs for each DRG were estimated from the Medicare reimbursement rate. Clopidogrel was assumed to be given for 1 year, priced at $4.22/day. Life expectancy gain as a result of the prevention of death, myocardial infarction, and stroke was estimated using Framingham data. RESULTS: Within 28 days, adding clopidogrel to aspirin is likely a dominant strategy, lowering the event rate (9.2% vs. 10.1%) without an increase in cost ($7791 vs. $7797). Over a lifetime, treating for 1 year with clopidogrel-plus-aspirin produced a gain of 0.1187 life years at an incremental cost of $1269 compared to aspirin alone, resulting in an incremental cost-effectiveness ratio (ICER) of $10,691/life year gained. Sensitivity analyses showed that ICERs for clopidogrel are well below the common benchmark ceiling ratio of $50,000/life year gained. CONCLUSIONS: Addition of clopidogrel to aspirin, given up to 1 year, in the setting of STEMI is a highly cost-effective strategy.

One-year costs in patients with a history of or at risk for atherothrombosis in the United States.

BACKGROUND: Atherothrombosis is the underlying cause of cardiovascular, cerebrovascular, and peripheral arterial disease and is the leading cause of death in the industrialized world. The objectives of the present study are (1) to examine the annual costs associated with vascular events and interventions that require hospitalization, as well as long-term medication use for the management of associated risk factors, in a US population of outpatients with multiple atherothrombotic risk factors or a history of symptomatic disease and (2) to compare costs across patient subgroups defined according to specific arterial bed(s) affected and the number of affected arterial beds. METHODS AND RESULTS: The international REduction of Atherothrombosis for Continued Health (REACH) Registry enrolled outpatients > or =45 years of age who had established coronary artery, cerebrovascular, or peripheral artery disease or > or =3 atherothrombotic risk factors. Data on risk factors, associated medications, and vascular hospitalizations and interventions were collected. Of the total 68 236-patient REACH cohort, 25 763 were enrolled from US sites. Complete 1-year data were available for 23 974 (93%) of the US patients. Annualized medication costs ranged from $2401 to $3481. Mean annual hospitalization costs per patient were $1344, $2864, $4824, and $8155 for patients with 0 (n=6145), 1 (n=14 353), 2 (n=3106), and 3 (n=370) affected arterial beds at baseline (P<0.0001 for trend). Among patients with 1 affected arterial bed, mean hospitalization costs were $2999, $2010, and $3911 for patients with coronary artery disease (n=11 063), cerebrovascular disease (n=2613), and peripheral arterial disease (n=677), respectively. Annualized medication costs ranged from $2401 to $3481. CONCLUSIONS: These results reveal the high economic burden of atherothrombosis-related clinical events and procedures and the especially high economic burden associated with polyvascular disease.