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Randomized Controlled Trial
. 2022 Jan;22(1):93-104.
doi: 10.1007/s40256-021-00491-9. Epub 2021 Jul 31.

Cost-Consequence Analysis of Using Cangrelor in High Angiographic Risk Percutaneous Coronary Intervention Patients: A US Hospital Perspective

Ivar S Jensen  1 , Elizabeth Wu  2 , Philip L Cyr  2   3 , Marc Claussen  4 , Thomas Winkler  4 , Khalid Salahuddin  4 , Jayne Prats  5 , Kenneth W Mahaffey  6 , Charles Michael Gibson  7 , Philippe Gabriel Steg  8 , Gregg W Stone  9 , Deepak L Bhatt  10
Affiliations
Randomized Controlled Trial

Cost-Consequence Analysis of Using Cangrelor in High Angiographic Risk Percutaneous Coronary Intervention Patients: A US Hospital Perspective

Ivar S Jensen et al. Am J Cardiovasc Drugs. 2022 Jan.

Abstract

Objectives: The objective of this study was to evaluate a US hospital's cost implications and outcomes of cangrelor use in percutaneous coronary intervention (PCI) patients with two or more angiographic high-risk features (HRFs), including avoidance of oral P2Y12 inhibitor pretreatment in patients requiring cardiac surgery. Intravenous cangrelor provides direct, immediate onset and rapid-offset P2Y12 inhibition, which may reduce the necessity for oral P2Y12 pretreatment.

Methods: A decision analytic model was developed, estimating the annual impact over 3 years of cangrelor availability. Ischemic and bleeding events (48 h) from randomized clinical trial data were extrapolated to 30 days. Event costs were from the CHAMPION PHOENIX Economics substudy. Rates of coronary artery disease (CAD) presentation, PCI, oral P2Y12 pretreatment, and inpatient hospitalization costs were from published literature and clinical experts. Scenario analyses evaluated the impact of cangrelor availability on potential reduced P2Y12 pretreatment rates by 50-100%. Drug costs were 2019 wholesale acquisition costs and, where necessary, all costs were adjusted to 2019 dollars.

Results: In a hospital treating 1000 CAD PCI inpatients annually, increasing cangrelor use from 11 to 32% resulted in a reduction in 48-h ischemic events/year by 5.7%, while bleeding events increased by 2.9%. Total costs of $1,135,472 declined 12.8%, with a 50% reduction in P2Y12 pretreatment or 30% with no pretreatment. Savings were driven by a decrease in ischemic events, decrease in glycoprotein IIb/IIIa inhibitor use, and less need for and shorter oral P2Y12 inhibitor washout period for surgery patients.

Conclusion: Use of cangrelor in patients with two or more angiographic HRFs may improve outcomes and lower hospital budgets, mainly from avoiding surgery delays necessitated by oral P2Y12 inhibitor pretreatment.

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Conflict of interest statement

Ivar S. Jensen, Elizabeth Wu, and Philip L. Cyr are employees of PrecisionHEOR, which provides consulting services to the pharmaceutical industry, including Chiesi, Inc. Marc Claussen and Khalid Salahuddin are employees of Chiesi, Inc.; Thomas Winkler was an employee of Chiesi at the time of developing this analysis; and Jayne Prats is a consultant to Chiesi, Inc. Kenneth W. Mahaffey’s financial disclosures can be viewed at http://med.stanford.edu/profiles/kenneth-mahaffey. C. Michael Gibson receives research support and consulting fees from Janssen and Johnson & Johnson, and also receives consulting fees from Bayer. Gabriel Steg discloses the following relationships: research grant from Amarin, Bayer, Sanofi, and Servier, and speaking or consulting fees from Amarin, Amgen, AstraZeneca, Bayer/Janssen, Boehringer-Ingelheim, Bristol-Myers-Squibb, Chiesi, Idorsia, Myokardia, Novartis, Novo-Nordisk, Pfizer, Regeneron, Sanofi, Servier, and The Medicines Company. Gregg W. Stone has received speaker or other honoraria from Cook, Terumo, QOOL Therapeutics, and Orchestra Biomed, and has served as a consultant to Valfix, TherOx, Vascular Dynamics, Robocath, HeartFlow, Gore, Ablative Solutions, Miracor, Neovasc, V-Wave, Abiomed, Ancora, and MAIA. Deepak L. Bhatt discloses the following relationships: Advisory Board: Cardax, CellProthera, Cereno Scientific, Elsevier Practice Update Cardiology, Janssen, Level Ex, Medscape Cardiology, MyoKardia, NirvaMed, Novo Nordisk, PhaseBio, PLx Pharma, and Regado Biosciences; Board of Directors: Boston VA Research Institute, Society of Cardiovascular Patient Care, and TobeSoft; Chair: American Heart Association Quality Oversight Committee; Data Monitoring Committees: Baim Institute for Clinical Research (formerly Harvard Clinical Research Institute, for the PORTICO trial, funded by St. Jude Medical, now Abbott), Cleveland Clinic (including for the ExCEED trial, funded by Edwards), Contego Medical (Chair, PERFORMANCE 2), Duke Clinical Research Institute, Mayo Clinic, Mount Sinai School of Medicine (for the ENVISAGE trial, funded by Daiichi Sankyo), and Population Health Research Institute; Honoraria: American College of Cardiology (Senior Associate Editor, Clinical Trials and News, ACC.org; Chair, ACC Accreditation Committee), Baim Institute for Clinical Research (formerly Harvard Clinical Research Institute; RE-DUAL PCI Clinical Trial Steering Committee funded by Boehringer Ingelheim; AEGIS-II executive committee funded by CSL Behring), Belvoir Publications (Editor in Chief, Harvard Heart Letter), Canadian Medical and Surgical Knowledge Translation Research Group (Clinical Trial Steering Committees), Duke Clinical Research Institute (Clinical Trial Steering Committees, including for the PRONOUNCE trial, funded by Ferring Pharmaceuticals), HMP Global (Editor in Chief, Journal of Invasive Cardiology), Journal of the American College of Cardiology (Guest Editor, Associate Editor), K2P (Co-Chair, interdisciplinary curriculum), Level Ex, Medtelligence/ReachMD (CME steering committees), MJH Life Sciences, Population Health Research Institute (for the COMPASS Operations Committee, Publications Committee, Steering Committee, and USA national co-leader, funded by Bayer), Slack Publications (Chief Medical Editor, Cardiology Today’s Intervention), Society of Cardiovascular Patient Care (Secretary/Treasurer), WebMD (CME Steering Committees); Other: Clinical Cardiology (Deputy Editor), NCDR-ACTION Registry Steering Committee (Chair), VA CART Research and Publications Committee (Chair); Research Funding: Abbott, Afimmune, Amarin, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Cardax, CellProthera, Cereno Scientific, Chiesi, CSL Behring, Eisai, Ethicon, Ferring Pharmaceuticals, Forest Laboratories, Fractyl, Garmin, HLS Therapeutics, Idorsia, Ironwood, Ischemix, Janssen, Lexicon, Lilly, Medtronic, MyoKardia, NirvaMed, Novartis, Novo Nordisk, Owkin, Pfizer, PhaseBio, PLx Pharma, Regeneron, Roche, Sanofi, Synaptic, The Medicines Company, and 89Bio; Royalties: Elsevier (Editor, Cardiovascular Intervention: A Companion to Braunwald’s Heart Disease); Site Co-Investigator: Abbott, Biotronik, Boston Scientific, CSI, St. Jude Medical (now Abbott), Svelte; Trustee: American College of Cardiology; and Unfunded Research: FlowCo, Merck, Takeda.

Figures

Fig. 1
Fig. 1
Decision analytic model structure. CABG coronary artery bypass graft, CHD coronary heart disease, GPI glycoprotein IIb/IIIa inhibitors, NSTEMI non-ST segment elevation myocardial infarction, PCI percutaneous coronary intervention, SA stable angina, STEMI ST segment elevation myocardial infarction, UA unstable angina
Fig. 2
Fig. 2
(A) 48-hour ischemic events; (B) 30-day ischemic events; (C) 48-hour bleeding events; and (D) 30-day bleeding events. GUSTO Global Use of Strategies to Open Occluded Arteries, IDR ischemia-driven revascularization, MI myocardial infarction, ST stent thrombosis, TIMI thrombolysis in myocardial infarction
Fig. 3
Fig. 3
Total costs and budget impact (A) Scenario: 50% reduction in pretreatment; (B) Scenario: 100% reduction in pretreatment. GPI glycoprotein IIb/IIIa inhibitors
Fig. 4
Fig. 4
Deterministic sensitivity analysis on the 3-year cumulative budget impact (top 10 most influential model parameters). The values on the bars represent the low and high parameter estimate used for the sensitivity analysis. The size of the bar indicates the calculated 3-year cumulative budget impact with the respective low (input reduced by 20%) or high (input increased by 20%) parameter estimate. The base 3-year cumulative budget impact is −$102,289. CHD coronary heart disease, Clopi clopidogrel, GPI glycoprotein IIb/IIIa inhibitors, MACE major adverse cardiovascular event, MI myocardial infarction, PCI percutaneous coronary intervention
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