OBJECTIVES: To determine the cost-effectiveness of CYP2C19 genotyping in antiplatelet therapy selection for patients with coronary artery disease (CAD) undergoing percutaneous coronary intervention (PCI) from the US healthcare payer’s perspective.
METHODS: A decision tree model was developed to project the 30-day and one-year medical costs (in 2014 US$) and outcomes for a hypothetical closed cohort of CAD patients undergoing PCIs for three antiplatelet treatment strategies: universal clopidogrel, universal prasugrel, and genotype-guided therapy selection. Outcomes included major adverse cardiovascular events (defined as death, myocardial infarction, ischemic stroke, or stent thrombosis) and major bleeding events, and costs to avoid these events. Model input estimates were collected from published data. Base-case scenario analysis and probabilistic sensitivity analysis were completed.
RESULTS: Base-case scenario results at 30 days indicated the incremental cost per major event avoided for genotype-guided treatment was $8,525 and $42,198 compared to universal clopidogrel and prasugrel, respectively. At one year, the incremental cost per adverse event avoided for genotype-guided treatment was $50,308 and was a dominant intervention when compared to universal clopidogrel and prasugrel, respectively. The probabilistic sensitivity analysis indicated that at an annual willingness-to-pay threshold of $50,000, the genotype-guided treatment was cost-effective at 30 days and one year in 62% and 70% of simulations, respectively. Universal clopidogrel was rarely cost-effective at 30 days and was cost-effective in 30% of simulations at one year. Universal prasugrel was cost-effective in 38% of simulations at 30 days and rarely at one year.
CONCLUSION: These results indicate that implementing a genotype-guided approach in antiplatelet therapy selection in clinical practice is potentially a cost-effective strategy that could help avoid adverse outcomes. This could help health systems achieve lower readmission rates within the first 30 days following PCI and suggests that reimbursement for CYP2C19 genetic testing is a worthwhile investment from the perspective of third party payers.
