Economic evaluation of restrictive vs. liberal transfusion strategy following acute myocardial infarction (REALITY): trial-based cost–effectiveness and cost–utility analyses

Abstract

Aim To estimate the cost effectiveness and cost utility ratios of a restrictive vs liberal transfusion strategy in acute myocardial infarction (AMI) patients with anemia. Methods and Results Patients (n = 666) with AMI and hemoglobin between 7-8 and 10 g/dL recruited in 35 hospitals in France and Spain were randomly assigned to a restrictive (n = 342) or a liberal (n = 324) transfusion strategy with 1-year prospective collection of resource utilization and quality of life using the EQ5D3L questionnaire. The economic evaluation was based upon 648 patients from the per-protocol population. The outcomes were 30-day and 1-year cost-effectiveness, with major adverse cardiovascular event averted (MACE) as the effectiveness outcome; and 1-year cost utility ratio. The 30-day incremental cost-effectiveness ratio was €33,065€ saved per additional MACE averted with the restrictive versus the liberal strategy, with an 84% probability for the restrictive strategy to be cost-saving and MACE reducing (i.e.dominant). At 1-year, the point estimate of the cost-utility ratio was 191,500 € saved per QALY gained; however cumulated MACE were outside the pre-specified non-inferiority margin, resulting in a decremental cost effectiveness ratio with a point estimate of €72,000 saved per additional MACE with the restrictive strategy. Conclusion In patients with acute myocardial infarction and anemia, the restrictive transfusion strategy was dominant (cost-saving and outcome-improving) at 30 days. At 1 year, the restrictive strategy remained cost-saving but clinical noninferiority on MACE was no longer maintained. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02648113.

Transfusion Thresholds for Acute Coronary Syndromes—Insights From the TRICS‐III Randomized Controlled Trial, Systematic Review, and Meta‐Analysis

“…It is possible that differences in preexisting anemia or transfusion protocol suspensions may have led to bias in the effect estimates. Emerging evidence suggests that restrictive transfusion strategies are no longer cost‐effective after 1 year 6 ; therefore, adoption of liberal strategies may improve patient outcomes without increasing cost burden to the health care system. This unrealized benefit may be considerably large, as 5 of 6 respondents from a recent poll by the American College of Cardiology reported using a restrictive transfusion strategy in their current clinical practice for this patient population.…”