Análisis de coste efectividad con los nuevos antiagregantes.
Causas de infrautilización en España
Mesa redonda: Antiagregación. 12/06/2014
Dr. José Luis FerreiroHospital Universitario de Bellvitge - IDIBELLÁrea de Enfermedades del CorazónUnidad de Cardiología Intervencionista - Laboratorio de Investigación Cardiovascular
CONFLICTS OF INTEREST
• Honoraria for lectures:– Eli Lilly Co; Daiichi Sankyo, Inc.; AstraZeneca; Roche
Diagnostics
• Advisory boards:– AstraZeneca; Eli Lilly Co; Ferrer, The Medicines
Company
• Research grants:– Spanish Society of Cardiology; AstraZeneca
DISCLOSURES
• I am not an expert in cost-effectiveness…
…but I will do my best
• The intention is to compare certain aspects of
new P2Y12 inhibitors (not among them) vs.
clopidogrel
INDEX
• Cost-effectiveness
• Underuse of new antiplatelet agents in Spain?
• Reasons for underutilization
COST-EFFECTIVENESS
Clopidogrel Prasugrel Ticagrelor
PVP IVAClopidogrel 75mg 28 comp:
21,04€ (costof reference)
Efient 10mg 28 comp: 63,38€
Efient 5mg 28 comp: 57,68€Brilique 90mg 56 comp: 89,61€
Cost of treatment
(year)280 € 824 € 1.171 €
Incremental cost
(year) + 544 € + 891 €
Incremental cost of treatment with the new ADP antagonists
COST-EFFECTIVENESS
ACS
Variable Prasugrel Ticagrelor
NNT (CI 95%) ICE (CI 95%) NNT (CI 95%) ICE (CI 95%)
CV death, non-fatal MI,
non-fatal stroke43 (33-88)
25.024 €(17.408-47.872 €)
56 (39-113) 49.896 €(34.749-100.683 €)
CV death -- n.a. 95 (69-223)84.645 €
(57.024-206.712 €)
Non-fatal MI 46 (33-73)25.024 €
(17.952-39.712 €)93 (60-300)
82.683 €
(53.460-267.300 €)
Non-fatal stroke -- n.a. -- n.a.
Death by any cause --n.a.
79 (56-158)70.389 €
(49.896-140.778 €)
Stent thrombosis81 (65-117) 44.064 €
(33.360-63.648 €)1.771 (106-590)
157.451 €
(94.446-525.690 €)
Incremental cost-effectiveness compared to clopidogrelPrasugrel: 15 months / Ticagrelor: 12 months
COST-EFFECTIVENESS
Too simplistic approach…
COST-EFFECTIVENESS
AVAC / QALYUSA: 50.000$ = 36.275€
UK: 30.000£ = 35.190€
Prasugrel Ticagrelor
ACS 3.435£ (4.029€) ACS 3.521£ (4.130€)
STEMI 2.167£ (2.542€) STEMI 2.551£ (2.992€)
NSTEACS / UA 4.494£ (5.271€) NSTEACS 5.217£ (6.120€)
UA 5.310£ (6.229€)
COST-EFFECTIVENESSCost-effectiveness acceptability curve in Spain
ACS-PCI ACS
Davies A et al. Farm Hosp. 2013;37:307-16 Delgado JL et al. XXXII Jornadas de Economía de la Salud. 2012
Prasugrel Ticagrelor
SCA 9.489 € SCA 3.944 €
IAMEST 5.913 € IAMEST 4.035 €
SCASEST / AI 12.414 € SCASEST 3.860 €
AI 4.971 €
Prasugrel and ticagrelor are more cost-effective than clopidogrel
with a threshold of 30.000€/QALY gained
Differences in methodology: unable to compare among drugs
UNDERUSE OF NEW
ANTIPLATELET AGENTS IN SPAIN?
USE OF NEW P2Y12 ANTAGONISTS
STEMI NSTEACS
SWEDE-HEART Registry
Wallentin L et al. Thromb Haemost. 2014;112
Orange = Clopidogrel and TicagrelorPurple = TicagrelorYellow = Clopidogrel and PrasugrelPink = PrasugrelGreen = Clopidogrel
USE OF NEW P2Y12 ANTAGONISTS
Alexopoulos D et al. Am Heart J. 2014;167:68-76.e2
GRAPE Registry: 8 PCI hospitals from Greece
In-hospital treatment
Use of new APT(only+switch)
Overall (n=1794) 59.3% (489 + 575)
STEMI (n=941) 63.4% (335 + 262)
NSTEMI + UA (n=853) 54.7% (154 + 313)
Source of data: IMS Health.
UNDERUTILIZATION IN SPAIN?
April 2014 PRASUGREL TICAGRELOR CLOPIDOGREL
ESPAÑA 11,3 9,8 71,3ANDALUCIA 12,4 11,6 69,1ARAGON 6,6 10,5 73,9ASTURIAS 4,3 6,8 76,0BALEARES 8,8 15,4 65,5CANARIAS 12,5 7,1 76,4CANTABRIA 14,0 5,1 63,6CASTILLA LA MANCHA 11,0 14,7 67,6CASTILLA Y LEÓN 14,3 5,3 72,5CATALUÑA 8,8 8,3 78,1CEUTA 9,2 4,0 78,2C. VALENCIANA 12,5 12,5 66,2EXTREMADURA 8,2 18,8 64,3GALICIA 5,4 1,8 83,3LA RIOJA 11,5 10,6 68,9MADRID 12,5 12,5 66,8MELILLA 17,2 11,7 80,8MURCIA 4,5 9,5 71,3NAVARRA 8,7 9,7 77,9PAIS VASCO 8,2 1,7 65,6
Market share / Percentage of sales (not percentage of patients)
Caution with interpretation: What is the percentage of clopidogrel due to an ACS?
Differences in cost (e.g. if a drug is more expensive, this value
overstimate the real percentage of patients treated)
Source of data: IMS Health.
UNDERUTILIZATION IN SPAIN?
April 2014 PRASUGREL TICAGRELOR CLOPIDOGREL
ESPAÑA 3,7 2,2 92,0ANDALUCIA 4,1 2,7 92,0ARAGON 2,1 2,3 94,3ASTURIAS 1,3 1,4 94,5BALEARES 3,0 3,7 92,2CANARIAS 3,9 1,6 92,5CANTABRIA 4,5 1,2 91,0CASTILLA LA MANCHA 3,7 3,5 90,1CASTILLA Y LEÓN 4,6 1,2 93,1CATALUÑA 2,7 1,8 93,9CEUTA 2,8 0,8 95,0C. VALENCIANA 4,2 3,0 91,2EXTREMADURA 2,8 4,6 90,3GALICIA 1,5 0,4 95,3LA RIOJA 3,6 2,4 86,5MADRID 5,9 2,8 88,3MELILLA 1,4 2,0 96,6MURCIA 2,8 2,2 93,7NAVARRA 2,3 0,3 87,5PAIS VASCO 5,0 1,0 89,0
DOTs (days of treatment), accounting sales by price and pills/day
Caution with interpretation: What is the percentage of clopidogrel due to an ACS?
UNDERUTILIZATION IN SPAIN?
Let’s play… (do not consider as real data)
% of clopidogrel due toACS
ClopidogrelNew agents
(Prasugrel + Ticagrelor)
25% due to ACS 79.7% 20.3% (12.7 + 7.7)
50% due to ACS 88.7% 11.3% (7.0 + 4.3)
75% due to ACS 92.2% 7.8% (4.8 + 3.0)
Assuming use only of clopi / pras / tica in ACS…
It might even vary among regions…
REASONS FOR
UNDERUTILISATION
REASONS FOR UNDERUTILIZATION
• Increased short-term costs
– Cost-effectiveness often not considered
• Therapeutic / Clinical inertia
– Failure of health care providers to initiate or intensify therapy
when indicated
– Encompasses the underuse of therapy that is efficacious and
effective in preventing serious endpoint clinical outcomes
– Particularly important in common chronic diseases in which
certain therapies have adequate evidence of effectiveness
Allen JD et al. J Manag Care Pharm. 2009;167:690-5
Allen JD et al. J Manag Care Pharm. 2009;167:690-5
Factors contributing to apparent clinical inertia (hypertension)
THERAPEUTIC INERTIA
Non-Adherence
BALANCING ISCHEMIA / BLEEDING
Inhibition of platelet aggregation
High risk of
ischemic events
High risk of
bleeding events“Sweet spot”
Ischemic risk Bleeding riskIschemic risk Bleeding risk
Ferreiro JL et al. Thromb Haemost 2010;103:1128-35.
Several agents: Individualize therapy‘‘The lower the bleeding risk, the higher the ischemic risk’’
CONCLUSIONS• Prasugrel and Ticagrelor are cost-effective when compared to clopidogrel
• New P2Y12 antagonists in Spain probably underused
– Differences among regions
– Concern: interruption/change of treatment during follow-up
• Several reasons for underutilization:
– Short-term costs
– Therapeutic inertia: Proactive measures are needed
• Challenge: Not to reach a percentage, but to individualize therapy
(balance ischemia/bleeding) and choose the best drug for each patient
GRACIAS POR SU ATENCIÓN