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