RTI uses cookies to offer you the best experience online. By clicking “accept” on this website, you opt in and you agree to the use of cookies. If you would like to know more about how RTI uses cookies and how to manage them please view our Privacy Policy here. You can “opt out” or change your mind by visiting: http://optout.aboutads.info/. Click “accept” to agree.
Cost-effectiveness of CYP2C19-guided P2Y(12) inhibitors in veterans undergoing percutaneous coronary intervention for acute coronary syndromes
Dong, O. M., Friede, K. A., Chanfreau-Coffinier, C., & Voora, D. (2023). Cost-effectiveness of CYP2C19-guided P2Y(12) inhibitors in veterans undergoing percutaneous coronary intervention for acute coronary syndromes. European heart journal. Quality of care & clinical outcomes, 9(3), 249-257. https://doi.org/10.1093/ehjqcco/qcac031
AIM: CYP2C19-guided P2Y12 inhibitor selection can reduce cardiovascular events and bleeding in patients with acute coronary syndromes (ACS) post-percutaneous coronary intervention (PCI). The 12-month cost-effectiveness of CYP2C19-guided P2Y12 inhibitor selection for Veterans post-ACS/PCI was evaluated from the Veteran Health Administration's (VHA) perspective.
METHODS AND RESULTS: Using average annualized PCI volumes and P2Y12 inhibitor use from VA data, a decision-analytic model simulated CYP2C19 testing versus no testing outcomes in 2800 hypothetical Veterans receiving PY212 inhibitor for 12 months post-ACS/PCI (74% clopidogrel, 5% prasugrel, 21% ticagrelor use at baseline without testing). CYP2C19 loss-of-function (LOF) carrier prevalence was 28%. Model inputs were from studies (bleeding/ischemic events, CYP2C19-guided therapy effect, health state utilities, CYP2C19 LOF carrier prevalence) and VHA administrative data (costs of events, drugs, CYP2C19 testing; PCI volumes, P2Y12 inhibitor prescriptions). The primary outcome was cost (2020 US${\$}$) per quality-adjusted life year (QALY) gained. Base-case scenario, probabilistic sensitivity analyses, and scenario analyses were completed. CYP2C19-guided therapy resulted in 496 (24%) escalations (clopidogrel to prasugrel/ticagrelor) and 465 (65%) de-escalations (prasugrel/ticagrelor to clopidogrel). CYP2C19 testing averted 1 stroke, 27 myocardial infarctions, 8 cardiovascular-related deaths, and caused 3 bleeds. CYP2C19 testing (vs no testing) was dominant in base-case scenario (0.0027 QALYs gained, ${\$}$527 saved/person) and in 97.1% of simulations, making it cost-effective and high-value. In scenario analyses, de-escalation in conjunction with escalation is required for CYP2C19 testing to be cost-effective and high-value.
CONCLUSIONS: In Veterans post-ACS/PCI, CYP2C19-guided P2Y12 inhibitor selection can improve cardiovascular outcomes and lower costs for the VHA within 12 months of implementation.