Cost-Effectiveness of Multigene Pharmacogenetic Testing in Patients With Acute Coronary Syndrome After Percutaneous Coronary Intervention
Cost-Effectiveness of Multigene Pharmacogenetic Testing in Patients With Acute Coronary Syndrome After Percutaneous Coronary Intervention
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DOI：
10.1016/j.jval.2019.08.002
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发表时间：
2020-01-01
期刊：
影响因子：
4.5
通讯作者：
Wiltshire, Tim
中科院分区：
文献类型：
--
作者：
Dong, Olivia M.;Wheeler, Stephanie B.;Wiltshire, Tim
目的：评价多基因检测的成本效益（CYP 2C 19、SLCO 1B 1、CYP 2C 9、VKORC 1）与单基因检测（CYP 2C 19）和标准治疗相比（无基因分型）在急性冠状动脉综合征（ACS）患者接受经皮冠状动脉介入治疗（PCI）从医疗保险的角度。开发了一种混合决策树/马尔可夫模型来模拟ACS患者PCI后需要抗血小板治疗（CYP 2C 19指导抗血小板选择）、他汀类药物治疗（SLCO 1B 1指导他汀类药物选择）和抗凝治疗（CYP 2C 9/VKORC 1指导华法林剂量）。主要结局是获得的每质量调整生命年（Qs）的成本（2016美元）。成本和季度折扣率为每年3%。概率敏感性分析（PSA）改变输入参数（事件概率、处方成本、事件成本、健康状态效用）来估计获得的每个QALY的成本变化。基础情况折扣结果表明，在12个月、24个月和生命周期时，每增加一个QALY的成本分别为59 876美元、33 512美元和3780美元，与标准治疗相比，在所有时间范围内，单基因检测都被多基因检测所主导。PSA折扣结果表明，在50 000美元/QALY获得的支付意愿阈值，多基因测试在大多数模拟中具有最高的成本效益概率，在24个月（61%）和整个生命周期（81%）。根据预测的模拟，与单基因检测相比，多基因检测在24个月内和整个生命周期内对PCI后ACS的Medicare患者具有更高的成本效益。基因检测和护理标准，可以帮助优化药物处方，以改善患者的结果。
Objective: To evaluate the cost-effectiveness of multigene testing (CYP2C19, SLCO1B1, CYP2C9, VKORC1) compared with singlegene testing (CYP2C19) and standard of care (no genotyping) in acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI) from Medicare's perspective.Methods: A hybrid decision tree/Markov model was developed to simulate patients post-PCI for ACS requiring antiplatelet therapy (CYP2C19 to guide antiplatelet selection), statin therapy (SLCO1B1 to guide statin selection), and anticoagulant therapy in those that develop atrial fibrillation (CYP2C9/VKORC1 to guide warfarin dose) over 12 months, 24 months, and lifetime. The primary outcome was cost (2016 US dollar) per quality-adjusted life years (QALYs) gained. Costs and QALYs were discounted at 3% per year. Probabilistic sensitivity analysis (PSA) varied input parameters (event probabilities, prescription costs, event costs, health-state utilities) to estimate changes in the cost per QALY gained.Results: Base-case-discounted results indicated that the cost per QALY gained was $59 876, $33 512, and $3780 at 12 months, 24 months, and lifetime, respectively, for multigene testing compared with standard of care. Single-gene testing was dominated by multigene testing at all time horizons. PSA-discounted results indicated that, at the $50 000/QALY gained willingness-to-pay threshold, multigene testing had the highest probability of cost-effectiveness in the majority of simulations at 24 months (61%) and over the lifetime (81%).Conclusions: On the basis of projected simulations, multigene testing for Medicare patients post-PCI for ACS has a higher probability of being cost-effective over 24 months and the lifetime compared with single-gene testing and standard of care and could help optimize medication prescribing to improve patient outcomes.