Online Supplement for the following September 29, 2009 JACC article
TITLE: Cost Effectiveness of Enoxaparin in Acute ST-Segment Elevation Myocardial Infarction: The ExTRACT-TIMI 25 Study
AUTHORS: Leo Marcoff, MD, Zugui Zhang, PHD, Wei Zhang, MS, Edward Ewen, MD, Claudine Jurkovitz, MD, MPH, Prisca Leguet,
PHARMD, Paul Kolm, PHD, William S. Weintraub, MD
SUPPLEMENT
1. Basic information
The distribution of patients by country across the world is listed in Electronic Supplement Table A. The number of patients varied from
4887 (24.9%) in Russia to 1 in France, and a total of 48 patients was enrolled in US. Electronic Supplement Table B shows hospital length of
stay, DRG/CPT codes, unit costs, % share for physician cost, and frequency by treatment group for index hospitalization and follow-up 30 days.
2. Subgroup analysis for 30 days and lifetime
The results of subgroup analysis for the 30 days costs and costs associated with life year lost by treatment groups were shown in Electronic
Supplement Table C. The results for subgroups in total 30 days costs resemble for the overall population. For lifetime, the costs in the
enoxaparin arm were higher in all subgroups. Life years lost for subgroups was presented in Electronic Supplement Table D. The results for
subgroups in life years gained are similar to the overall population.
Incremental cost-effective ratios for subgroups for 30 days and lifetime are
shown in Electronic Supplement Table E. For lifetime and for the most of the subgroups, the enoxaparin arm was cost effective as indicated by
the ICERs with 90% of estimates falling below the $50,000 per life year gained threshold, with the exception of patients who had prior PCI or
CABG.
Table A Distribution of Patients by Nations
Country
Argentina
Australia
Austria
Belgium
Bulgaria
Belarus
Brazil
Count
387
350
74
114
504
57
459
Percentage
1.89
1.71
0.36
0.56
2.46
0.28
2.24
Canada
118
0.58
Switzerland
Chile
China
Germany
Spain
Estonia
Finland
France
59
477
420
136
1279
103
30
1
0.29
2.33
2.05
0.66
6.25
0.50
0.15
0.00
United Kingdom
Greece
Hong Kong
Croatia
Hungary
India
Ireland
Israel
Italy
Jordan
South Korea
Lebanon
Lithuania
Latvia
Mexico
Malaysia
Netherlands
Norway
New Zealand
Poland
Portugal
Romania
Russia
Singapore
Slovakia
Sweden
Thailand
Turkey
Ukraine
Uruguay
United States
South Africa
625
200
6
211
484
753
10
867
624
3
328
36
46
39
341
94
642
43
483
1792
78
563
4887
33
370
66
117
951
790
11
48
370
3.05
0.98
0.03
1.03
2.36
3.68
0.05
4.23
3.05
0.01
1.60
0.18
0.22
0.19
1.67
0.46
3.13
0.21
2.36
8.75
0.38
2.75
23.86
0.16
1.81
0.32
0.57
4.64
3.86
0.05
0.23
1.81
Table B DRG/CPT Codes, Unit Costs, % of Share, and Frequency by Treatment Group Between Index Hospitalization Discharge and
30 Days
DRG
ICH & STROKE WITH
INFARCT
OTHER DISORDERS OF
THE EYE AGE >17 W CC
PULMONARY EMBOLISM
PLEURAL EFFUSION W
CC
PULMONARY EDEMA &
RESPIRATORY FAILURE
SIMPLE PNEUMONIA &
PLEURISY AGE >17 W/O
CC
OTHER RESPIRATORY
SYSTEM DIAGNOSES W/O
CC
CABG AND PCI
CABG AND CARDIAC
CATHETERIZATION
OTHER
CARDIOTHORACIC
PROCEDURES
CABG ONLY
MI WITH MAJOR
COMPLICATIONS,
DISCHARGED ALIVE*
MI WITHOUT MAJOR
COMPLICATIONS,
DISCHARGED ALIVE
MI--EXPIRED
HEART FAILURE
DEEP VEIN
Code
Frequency
ENOX UFH
ENOX
Hospital Physician
costs ($)
costs ($)
UFH
Hospital
Physician
costs ($)
costs ($)
14
9
20
Unit
Cost
($)
6231
Share
(%)
26
5
1
12
3
46
1
0
3930
40
0.38
0.2
0
0
78
85
3
1
1
2
6357
6167
28
33
2
0.6
0.5
0.2
0.6
1
0.2
0.4
87
2
1
6665
22
1
0.3
0.7
0.1
90
0
1
2527
35
0
0
0.3
0.1
102
0
1
2298
58
0
0
0.2
0.1
106
107
1
21
2
17
39713
28823
25
29
4
59
1
17
8
48
2
14
108
2
0
31282
22
6
1
0
0
109
121
110
5
111
5
21432
7763
24
27
230
4
55
1
233
4
56
1
122
57
50
4586
39
25
10
22
9
123
127
128
19
69
1
9
68
1
8346
5030
3291
18
28
40
15
34
0.3
3
10
0.1
7.
33
0.3
1
10
0.1
THROMBOPHLEBITIS
PERIPHERAL VASCULAR
DISORDERS W/O CC
ATHEROSCLEROSIS W CC
HYPERTENSION
CARDIAC CONGENITAL
& VALVULAR
DISORDERS AGE >17 W/O
CC
CARDIAC ARRHYTHMIA
& CONDUCTION
DISORDERS W/O CC
ANGINA PECTORIS
SYNCOPE & COLLAPSE
W/O CC
CHEST PAIN
OTHER CIRCULATORY
SYSTEM DIAGNOSES W/O
CC
BLEEDING (MAJOR AND
MINOR): COMPLICATION
OF TREATMENT W CC
REHABILITATION
CARDIAC
DEFIBRILLATOR
IMPLANT W/O CARDIAC
CATH
PCI
CARDIAC DEFIB
IMPLANT W CARDIAC
CATH W AMI/HF/SHOCK
131
1
2
2454
45
0.2
0.1
0.5
0.2
132
134
136
0
3
1
1
3
0
2864
2624
27534
44
47
52
0
0.8
0.3
0
0.4
0.1
0.3
0.8
0
0.1
0.4
0
139
10
12
2111
561
2
1
2
1
140
142
151
2
131
0
2150
2552
47
522
32
0.52
15
0.3
28
0
13
0
143
145
0
4
2
8
2346
2663
52
48
0
1
0
0.5
0.5
2
0.2
1
453
15
7
2461
59
4
24
2
1
462
515
7
1
9
3
12394
29884
21
18
8
3
2
0.5
11
9
2
2
516
535
358
2
351
0
13826
46291
32*
18**
483
9
155
2
475
0
152
0
856
818
279
1210
Enoxaparin
0.04
901
Total
931
CPT
COMPUTERIZED
TOMOGRAPHY (HEAD
SCAN)
MRI (HEAD SCAN)
TRANSCATHETER
PLACEMENT OF AN
70470
1
1
Unit costs ($)
378
75553
92980
124
63
143
66
5134
5574
64
34
270
1171
UFH
0.04
7
36
INTRACORONARY
STENT(S),
PERCUTANEOUS, WITH
OR WITHOUT OTHER
THERAPEUTIC
INTERVENTION, ANY
METHOD; SINGLE
VESSEL
CARDIAC
CATHETERIZATION
ELECTROPHYSIOLOGY
STUDIES
Length of Stay
93510
197
234
2326
45
53
93624
0
1
881
0
0.09
85
1295
97
1268
385
445
Total
Total subsequent costs
11.3 (8.1)**
11.2 (8.0)
(n=10,064)
(n=10,048)
ENOX=enoxaparin
UFH=unfractionated heparin
Share of % for DRG 112; ** Share of % for DRG 115
**: Days (standard Error)
†costs from year 2004 – obtained from URL: http://www.cms.hhs.gov/MedicareFeeforSvcPartsAB/Downloads/DRG04.pdf
Table C Cost Subgroup Analysis for Total 30 Days and Life Time
Overall
Age<65
Age>=65
Male
Female
BMI<30
BMI>=30
Prior MI
No Prior MI
Heart Failure
NO Heart Failure
Diabetes
No Diabetes
Prior Unstable angina
No Prior Unstable angina
Enoxaparin
($)
UFH
($)
95% confidence
interval
11,026
77,907
Difference
(EnoxaparinUFH)
102.5
1,207
11,129*
79,115
11,254*
91,054
10,918
58,930
11,316
79,279
10,521
78,581
11,210
78,238
10,823
82,406
10,932
71,977
11,166
80,236
14,178
38,866
10,979
81,095
12,011
76,440
10,978
79,639
10,704
74,206
11,296
11,299
90,220
10,580
57,762
11,294
78,387
10,137
76,316
11,075
77,084
10,830
81,225
11,012
70,715
11,015
78,978
13,055
35,508
10,924
80,042
11,978
74,319
10,862
78,542
10,642
71,948
11,175
-45.2
834.2
337.5
1,168.6
21.7
891.6
384
2265
135
1,153.3
-6.7
1,181
-80.2
1261.5
150.4
1,258
1,122.9
3,358.1
54.6
1,052.9
33
2,121.8
116
1097
62
2,258
121
-317, 227
179.5, 1,488.8
5, 670.0
96.3, 2,240.9
-226.6, 270.0
170, 1613.3
-3.6, 771.5
318.5, 4,210.8
-101.9, 372.3
346.3, 1,960.4
-470.0, 456.3
-354.4, 2,716.4
-660.2, 5,058
-866.1, 3389.1
-76.0, 376.8
502.5, 2013.4
78.5, 2,167.4
-1,185, 7,901
-160.1, 269.4
386.8, 1,719.0
-574, 639.8
29.6, 4,214.1
-109.5, 340.4
337.5, 1,857
-328.1, 450.3
806.3, 3,710.2
-131, 373.1
-108.5, 313.6,
491, 1923
Prior PCI or CABG
No Prior PCI or CABG
Fibrinolytic Agent:
Alteplase
Reteplase
Streptokinase
Tenecteplase
81,098
21,865
89,750
10,561
78,579
10,011
85,806
11,481
78,107
11,211
76,943
12,954
79,739
80,227
21,921
89,607
10,497
77,346
10,186
85,267
11,992
78,439
11,170
76,538
12,853
79,005
871
-66
143
64.3
1,233
-175
539
-519
-332
41
405
101
734
*In each cell, the first row indicates total 30 days costs, and the second row indicates
lifetime costs.
59.5, 1,682.7
-1,775, 1,644.3
-2973, 3,259
-127.8, 256.4
500.3, 1964.3
-441.4, 91.621
-39.91, 1118.5
-1470, 448.98
-1989, 1324.1
-431.4, 514.67
-556.1, 1366.7
-423.6, 626.08
-158.2, 1626.4
Table D Subgroup Analysis for Life Year Lost
#
Enoxaparin
#
UFH
95% confidence interval
0.8803
Difference
(EnoxaparinUFH)
0.1158
0.7644
Age<65
0.4521
0.5705
0.118
0.039, 0.198
Age>=65
1.2923
1.3871
0.095
-0.235, 0.0457
Male
0.5762
0.6539
0.078
0.006, 0.15
Female
1.3756
1.631
0.255
0.054, 0.457
BMI<30
0.7862
0.8746
0.088
0.006, 0.17
BMI>=30
0.6825
0.9029
0.22
0.057, 0.384
Prior MI
1.0703
1.3626
0.292
0.05, 0.535
No Prior MI
0.7163
0.8079
0.092
0.016, 0.168
Heart Failure
6.2409
6.7602
0.519
-1.163, 0.1246
No Heart Failure
0.4949
0.5842
0.089
0.03, 0.149
Diabetes
1.0754
1.3488
0.273
0.046, 0.501
No Diabetes
0.701
0.7955
0.094
0.018, 0.171
Prior Unstable angina
0.977
1.293
0.316
0.156, 0.476
No Prior Unstable angina
0.6772
0.7161
0.039
-0.119, 0.0416
Overall
0.0405,0.1880
Prior PCI or CABG
No Prior PCI or CABG
Fibrinolytic Agent:
Alteplase
Reteplase
Streptokinase
Tenecteplase
0.6119
0.7696
0.8058
0.6464
0.8177
0.6159
0.6111
0.893
0.9426
0.6806
0.8874
0.7372
-0.0008
0.123
0.137
0.034
0.07
0.121
-0.28, 0.2819
0.048, 0.199
0.033, 0.24
-0.309, 0.2407
-0.236, 0.097
-0.265, 0.0228
Table E Subgroup Analysis for Cost Effectiveness
ICER
Overall
Age<65
885
5,700
Likely a dominant strategy *
Dominated
%
0.1
0
Dominate
%
16.1
0
<$50,000/LYG
%
99.90
99.990
0
64.2
99.8
0.1
8.8
7.5
1.2
1.5
0.8
0.5
1.5
1.5
0.3
0.3
1.8
0.4
42.0
0.6
1.8
0.8
13.1
0.2
51.3
99.8
89.3
87.5
97.2
96.2
98.2
98.5
97.5
95.6
99.3
0.5
0.2
6.5
61.8
99.8
99.4
0.3
0.8
1
5.8
1.9
0
0
0.4
0.3
1
0.6
0
0
15.5
11.1
10.5
0
1.9
4.5
30.1
0
45.5
2.3
17.1
0.1
36.5
0.1
12.5
99.2
98.3
97.0
93.2
94.1
99.3
99.0
99.4
99.5
99.0
97.4
99.9
99.9
80.7
7,050
Age>=65
Male
Female
BMI<30
BMI>=30
3,559
12,323
278
11,465
1,503
8,868
1,529
13,047
Likely a dominant strategy
5,358
Prior MI
Likely a dominant strategy
4,315.7
No Prior MI
Heart Failure
NO Heart Failure
Diabetes
No Diabetes
Prior Unstable angina
No Prior Unstable angina
1,643
13,745
2,162
6,466
611
11,790
120
7,760
1,223
11,618
193
7,147
3,114
22,410
Likely a dominated strategy
Likely a dominated strategy
Prior PCI or CABG
No Prior PCI or CABG
Fibrinolytic Agent:
Alteplase
Reteplase
Streptokinase
Tenecteplase
521
9,985
1278.0
3941.0
14943.1
9724.1
597.5
5816.5
834.8
6053.8
15.7
23.7
0.2
28.2
73.4
51.5
17.1
0.1
0.2
0.6
0.4
36.7
37.9
8.7
15
2
2.9
12.4
26.5
0.1
89.8
4.1
49.2
28.7
36
5.2
34.2
3
47.1
99.9
98.8
99.3
99.5
59.1
62.0
79.4
77.7
94.7
93.6
*In each cell, the first row indicates the results of cost-effectiveness for the 30 days analysis, and the second row indicates the results of costeffectiveness for the lifetime analysis.