Coût-efficacité en vie réelle du ticagrélor : double thérapie antiplaquettaire pour l'infarctus du myocarde au Québec, Canada
In Canada, there are approximately 21,000 deaths and 84,069 hospitalizations related to myocardial infarction (MI) per year, representing approximately Can$1.27 billion in direct costs related to acute and chronic care. Despite the demonstrated health benefits of dual antiplatelet therapy (DAPT) after an MI, observed real-world persistence to treatment with ticagrelor-based DAPT in Québec is lower than that observed with other P2Y12 receptor inhibitors. The objective of this project was to develop a decision-making model to evaluate the cost-utility ratio of ticagrelor-DAPT under conditions of imperfect persistence in Quebec patients suffering from MI, and thus to determine whether a province-wide intervention to increase persistence would be justifiable. A decision tree describing the patient course in the first year following an MI was developed in order to compare four different durations of persistence with perfect adherence with ticagrelor-DAPT (3, 6, 9 and 12 months) to perfect adherence with a 12-month regimen clopidogrel-DAPT (reference treatment). Three clinical events were modeled: recurrent MI, cardiovascular death and major bleeding. The probabilities of these events were extracted from relevant randomized clinical trials using published Kaplan-Meier survival curves. The utilities needed to calculate the QALYs were derived from the literature. The costs were estimated from the Canadian literature and the list of medications from the Régie de l'assurance maladie du Québec and were expressed in Can$ 2018. The reference case analysis consisted of a probabilistic Monte Carlo simulation. At a mean cost per quality adjusted life year (QALY) gained of Can$43,398, the results of the base case analysis showed that 3 months of ticagrelor-DAPT had a 59.31% likelihood of being considered cost-effective using a willingness-to-pay threshold of Can$50,000/QALY. Moreover, the sensitivity analyses showed that the cost-effectiveness of ticagrelor-DAPT was sensitive to the cost of cardiovascular death and the cost of ticagrelor. Assuming a cost of ticagrelor compatible with a generic drug, the 4 durations of persistence with ticagrelor-DAPT are almost guaranteed to be profitable. When a generic cost of ticagrelor was assumed, 3 months, 6 months and 9 months of ticagrelor-DAPT were dominant and 12 months of ticagrelor-DAPT were highly likely to be cost-effective (98.8%). This analysis also conclude that as little as 3 months of ticagrelor-DAPT is likely to be cost-effective compared to 12 months of clopidogrel-DAPT. With a moderate to strong level of evidence, we therefore conclude that no specific intervention is warranted at the provincial policy level to improve persistence rate with ticagrelor treatment after MI.
Myocardial infarction Ticagrelor Persistence Economic evaluation Cost-effectiveness analysis Cost-utility analysis Modeling Decision analysis Health policy