OBJECTIVES: To determine the cost-effectiveness of multi-gene pharmacogenetic testing (CYP2C19, SLCO1B1, CYP2C9/VKORC1) for acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI) compared to single gene testing (CYP2C19) and usual care (no genotyping) from the perspective of Medicare.
METHODS: A decision tree model was developed to simulate the medical costs (2018 US$) and outcomes over a time horizon of 27 months for a hypothetical closed cohort of ACS patients undergoing PCI requiring antiplatelet (CYP2C19 to guide clopidogrel or prasugrel/ticagrelor selection), statin therapy (SLCO1B1 to guide simvastatin or alternative statin selection), and anticoagulant therapy in those that develop atrial fibrillation (CYP2C9/VKORC1 to guide warfarin dose). Outcomes included myalgia/myopathy, stroke, myocardial infarction, major bleed, thromboembolic events, deaths, and cost per quality adjusted life year (QALY) gained. Model input estimates were from published data. Cost and QALYs were discounted at 3%. Base-case scenario and probabilistic sensitivity analysis using 10,000 Monte Carlo simulations were completed.
RESULTS: Base-case scenario results indicated the discounted cost per QALY gained was $23,165 and $27,415 for multi-gene testing and single-gene testing, respectively, when compared to usual care. Both genotyping strategies resulted in fewer adverse outcomes when compared to usual care with more myalgia/myopathy, major bleeds, and thromboembolic events avoided on multi-gene testing when compared to single-gene testing. Probabilistic sensitivity analysis indicated that 100% of simulations were below the $50,000 willingness-to-pay threshold for both genotyping strategies when compared to usual care.
CONCLUSIONS: Implementing multi-gene or single-gene pharmacogenetic test for ACS patients undergoing PCI is cost-effective that could help optimize medication prescribing and avoid adverse outcomes when compared to usual care. Multi-gene testing appeared to be the most cost-effective strategy. Reimbursement for multi-gene pharmacogenetic testing may be a cost-effective investment from the perspective of Medicare to help health systems optimize medication prescribing and achieve better patient outcomes following PCI.
