Systematic review of the evidence on the cost-effectiveness of pharmacogenomics-guided treatment for cardiovascular diseases

Abstract

Purpose: To examine the evidence on the cost-effectiveness of implementing pharmacogenomics (PGx) in cardiovascular disease (CVD) care.

Methods: We conducted a systematic review using multiple databases from inception to 2018. The titles and abstracts of cost-effectiveness studies on PGx-guided treatment in CVD care were screened, and full texts were extracted.

Results: We screened 909 studies and included 46 to synthesize. Acute coronary syndrome and atrial fibrillation were the predominantly studied conditions (59%). Most studies (78%) examined warfarin-CYP2C9/VKORC1 or clopidogrel-CYP2C19. A payer's perspective was commonly used (39%) for cost calculations, and most studies (46%) were US-based. The majority (67%) of the studies found PGx testing to be cost-effective in CVD care, but cost-effectiveness varied across drugs and conditions. Two studies examined PGx panel testing, of which one examined pre-emptive testing strategies.

Conclusion: We found mixed evidence on the cost-effectiveness of PGx in CVD care. Supportive evidence exists for clopidogrel-CYP2C19 and warfarin-CYP2C9/VKORC1, but evidence is limited in other drug-gene combinations. Gaps persist, including unclear explanation of perspective and cost inputs, underreporting of study design elements critical to economic evaluations, and limited examination of PGx panel and pre-emptive testing for their cost-effectiveness. This review identifies the need for further research on economic evaluations of PGx implementation.

Keywords: cardiovascular disease; cost-effectiveness; disease management; economic evaluation; pharmacogenomics.

Fig. 1

Flowchart of the literature screening. *Exclusion criteria: 1) non-english study. 2) full text not available. 3) article types: conference paper/abstract, comment, review, short survey, editorial, note, letter, legal case, congress, newspaper articles, book chapter, guideline, erratum, study protocols. 4) not relevant to pharmacogenomics, e.g. genetic diagnostic testing, 5) no economic evaluation, 6) not cardiovascular diseases, 7) intervention not applied to human subjects.

Fig. 2

Cost categories included in the study. Costs included in the studies were categorized into these major types: pharmacogenomics (PGx) testing, other types of testing (e.g., international normalized ratio [INR] monitoring, platelet function tests), medications (e.g., warfarin, clopidogrel), event-related costs (e.g., bleeding, stroke), postevent-related costs (long-term management costs), no-events costs (medical care costs for patients without adverse events), all-cause costs (any costs occurred after the treatment was initiated), and indirect costs (e.g., transportation, food). Several studies did not report the cost categories used in the calculation.

Fig. 3

Comparison of cost-effectiveness with selected study characteristics. a Perspectives held in the studies, including payer (both public and private), provider, societal, and health-care system. Studies that did not report the perspectives used were categorized as no statement. b Funding support types. Combination types included private + public, public + nonprofit organization (NPO), and private + NPO. c Country/regions of the study population. Other countries/regions included Serbia, China, Croatia, Europe, Korea, New Zealand, Slovenia, Thailand, UK, UK and Sweden, United States and Canada. PGx pharmacogenomics.