Cost-Effectiveness of Multigene Pharmacogenetic Testing in Patients With Acute Coronary Syndrome After Percutaneous Coronary Intervention

Value Health. 2020 Jan;23(1):61-73. doi: 10.1016/j.jval.2019.08.002. Epub 2019 Sep 25.

Abstract

Objective: To evaluate the cost-effectiveness of multigene testing (CYP2C19, SLCO1B1, CYP2C9, VKORC1) compared with single-gene 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.

Keywords: acute coronary syndrome; multigene testing; pharmacogenetics; precision medicine.

Publication types

  • Comparative Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Acute Coronary Syndrome / diagnosis
  • Acute Coronary Syndrome / economics*
  • Acute Coronary Syndrome / mortality
  • Acute Coronary Syndrome / therapy*
  • Aged
  • Anticoagulants / adverse effects
  • Anticoagulants / economics*
  • Anticoagulants / therapeutic use*
  • Cost-Benefit Analysis
  • Cytochrome P-450 CYP2C19 / genetics
  • Cytochrome P-450 CYP2C9 / genetics
  • Decision Trees
  • Drug Costs*
  • Female
  • Humans
  • Hydroxymethylglutaryl-CoA Reductase Inhibitors / adverse effects
  • Hydroxymethylglutaryl-CoA Reductase Inhibitors / economics*
  • Hydroxymethylglutaryl-CoA Reductase Inhibitors / therapeutic use*
  • Liver-Specific Organic Anion Transporter 1 / genetics
  • Male
  • Markov Chains
  • Medicare / economics
  • Percutaneous Coronary Intervention / adverse effects
  • Percutaneous Coronary Intervention / economics*
  • Percutaneous Coronary Intervention / mortality
  • Pharmacogenomic Testing / economics*
  • Pharmacogenomic Variants*
  • Platelet Aggregation Inhibitors / adverse effects
  • Platelet Aggregation Inhibitors / economics*
  • Platelet Aggregation Inhibitors / therapeutic use*
  • Precision Medicine / economics
  • Predictive Value of Tests
  • Quality-Adjusted Life Years
  • Reproducibility of Results
  • Risk Factors
  • Time Factors
  • Treatment Outcome
  • United States
  • Vitamin K Epoxide Reductases / genetics

Substances

  • Anticoagulants
  • Hydroxymethylglutaryl-CoA Reductase Inhibitors
  • Liver-Specific Organic Anion Transporter 1
  • Platelet Aggregation Inhibitors
  • SLCO1B1 protein, human
  • CYP2C9 protein, human
  • Cytochrome P-450 CYP2C9
  • CYP2C19 protein, human
  • Cytochrome P-450 CYP2C19
  • VKORC1 protein, human
  • Vitamin K Epoxide Reductases