Cost-Utility of Aspirin and Proton Pump Inhibitors for Primary Prevention

Earnshaw, Stephanie; Scheiman, James M.; Fendrick, A. Mark; McDade, Cheryl; Pignone, Michael

doi:10.1001/archinternmed.2010.525

Cited by 44 publications

(32 citation statements)

References 23 publications

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“…Our findings are robust to several key assumptions in the model and suggest that guideline makers may need to reconsider their recommendations for primary prevention based on this cancer effect. 5 Consistent with our past modeling analyses, 10,11 we have identified a threshold for use of aspirin (in the absence of a cancer effect) that is below thresholds often advocated by others.…”

Section: Discussionsupporting

confidence: 85%

“…10,11,15 Because of significant differences in the quantity and strength of the evidence for aspirin effectiveness by sex and possibly by presence or absence of diabetes, we limited the current analysis to non-diabetic men. In the model, men begin in the healthy state and then transition through the model states in 12-month cycles (on-line Appendix Figure O-1).…”

Section: Methodsmentioning

confidence: 99%

“…Our previous analyses have found that aspirin appears to be more effective and less costly than no therapy in middle-aged men who are at 5 % or greater 10-year risk for coronary heart disease (CHD). 10, 11 Greving and colleagues found that aspirin was cost-effective in Dutch men at 10 % or greater risk. 12 In these analyses, the beneficial effects of prevention of non-fatal myocardial infarction outweighed the downsides of increased gastrointestinal bleeding and increased strokes.…”

Section: Introductionmentioning

confidence: 99%

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Effect of Including Cancer Mortality on the Cost-Effectiveness of Aspirin for Primary Prevention in Men

et al. 2013

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BACKGROUND: Recent data suggest that aspirin may be effective for reducing cancer mortality. OBJECTIVE: To examine whether including a cancer mortality-reducing effect influences which men would benefit from aspirin for primary prevention. DESIGN: We modified our existing Markov model that examines the effects of aspirin among middle-aged men with no previous history of cardiovascular disease or diabetes. For our base case scenario of 45-year-old men, we examined costs and life-years for men taking aspirin for 10 years compared with men who were not taking aspirin over those 10 years; after 10 years, we equalized treatment and followed the cohort until death. We compared our results depending on whether or not we included a 22 % relative reduction in cancer mortality, based on a recent meta-analysis. We discounted costs and benefits at 3 % and employed a third party payer perspective. MAIN MEASURE: Cost per quality-adjusted life year (QALY) gained. KEY RESULTS: When no effect on cancer mortality was included, aspirin had a cost per QALY gained of $22,492 at 5 % 10-year coronary heart disease (CHD) risk; at 2.5 % risk or below, no treatment was favored. When we included a reduction in cancer mortality, aspirin became cost-effective for men at 2.5 % risk as well (cost per QALY, $43,342). Results were somewhat sensitive to utility of taking aspirin daily; risk of death after myocardial infarction; and effects of aspirin on stroke, myocardial infarction, and sudden death. However, aspirin remained cost-saving or cost-effective (< $50,000 per QALY) in probabilistic analyses (59 % with no cancer effect included; 96 % with cancer effect) for men at 5 % risk. CONCLUSIONS: Including an effect of aspirin on cancer mortality influences the threshold for prescribing aspirin for primary prevention in men. If such an effect is real, many middle-aged men at low cardiovascular risk would become candidates for regular aspirin use.

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Section: Discussionsupporting

confidence: 85%

Section: Methodsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Effect of Including Cancer Mortality on the Cost-Effectiveness of Aspirin for Primary Prevention in Men

et al. 2013

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“…9 The associated cost and utility decrement with dyspepsia were included for patients with the side effect. 22,23 Mortality rates for the baseline population were initially adjusted in the model for age (starting at 70 years). 24 A patient's mortality risk was adjusted for age and postevent mortality risks (MI, ischemic stroke, and ICH) throughout the course of the patient's lifetime and disease progression.…”

Section: Decision Modelmentioning

confidence: 99%

Cost-Effectiveness of Apixaban, Dabigatran, Rivaroxaban, and Warfarin for Stroke Prevention in Atrial Fibrillation

Harrington

Armstrong

Nolan

et al. 2013

Stroke

233

159

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Background and Purpose-To estimate the cost-effectiveness of stroke prevention in patients with nonvalvular atrial fibrilla tion by using novel oral anticoagulants apixaban 5 mg, dabigatran 150 mg, and rivaroxaban 20 mg compared with warfarin. Methods-A Markov decision-analysis model was constructed using data from clinical trials to evaluate lifetime costs and quality-adjusted life-years of novel oral anticoagulants compared with warfarin. The modeled population was a hypothetical cohort of 70-year-old patients with nonvalvular atrial fibrillation, increased risk for stroke (CHADS 2 ≥1), renal creatinine clearance ≥50 mL/min, and no previous contraindications to anticoagulation. The willingness-to-pay threshold was $50 000/quality-adjusted life-years gained. Results-In

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“…Furthermore, the risk of upper gastrointestinal bleeding, 1 of the most common manifestations of major bleeding, often can be mitigated through the use of proton pump inhibitors. 41 However, ICH tends to have a comparatively higher rate of mortality and permanent disability than most other manifestations of major bleeding. The protocol of the largest PAR-1 antagonist trial to date was amended because of concerns about an excessive occurrence of ICH in patients with a previous stroke.…”

Section: Discussionmentioning

confidence: 99%

Risk of Intracranial Hemorrhage With Protease-Activated Receptor-1 Antagonists

Lee

Saver²,

Hong³

et al. 2012

Stroke

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Background and Purpose— Recent clinical trial data suggest that protease-activated receptor-1 (PAR-1) antagonists may increase the risk of intracranial hemorrhage. Our objective was to investigate the qualitative and quantitative risks of intracranial hemorrhage in patients receiving PAR-1 antagonist therapy. Methods— Pubmed, EMBASE, Cochrane Central Register of Controlled Trials, and Clinicaltrials.gov from 1966 to May 2012, were searched to identify relevant studies. We included randomized controlled trials that included a comparison of PAR-1 antagonist with placebo and in which the total number of patients and intracranial hemorrhage events were reported separately for active treatment and control groups. Summary incidence rates, relative risks, and 95% confidence intervals (CIs) were calculated using random-effects models. Between-study heterogeneity was assessed using the I 2 statistic. Results— In 9 PAR-1 antagonist trials with 42000 patients with a history of thrombotic vascular disease or acute coronary syndrome, PAR-1 antagonist treatment was associated with increased risk of intracranial hemorrhage (0.59% vs 0.30%; relative risk, 1.98; 95% CI, 1.46–2.68; P <0.00001; number needed to harm, 345). There was no heterogeneity across trials ( P =0.84; I 2 =0%), PAR-1 antagonist agent ( P =0.52), treatment duration ( P =0.38), or trial-qualifying event ( P =0.59). Risk of death from any cause or a cardiovascular cause did not differ between active treatment and control groups. Conclusion— In a pooled analysis of data from 9 trials, PAR-1 antagonist therapy was associated with an increased risk for intracranial hemorrhage.

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Cost-Utility of Aspirin and Proton Pump Inhibitors for Primary Prevention

Cited by 44 publications

References 23 publications

Effect of Including Cancer Mortality on the Cost-Effectiveness of Aspirin for Primary Prevention in Men

Effect of Including Cancer Mortality on the Cost-Effectiveness of Aspirin for Primary Prevention in Men

Cost-Effectiveness of Apixaban, Dabigatran, Rivaroxaban, and Warfarin for Stroke Prevention in Atrial Fibrillation

Risk of Intracranial Hemorrhage With Protease-Activated Receptor-1 Antagonists

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