Department of Biomedical Data Science, Stanford University, Stanford, CA, USA; Institute for Public Health Genetics, University of Washington, Seattle, WA, USA.
Department of Pharmacy, The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, University of Washington, Seattle, WA, USA.
Value Health. 2019 Nov;22(11):1231-1239. doi: 10.1016/j.jval.2019.05.015. Epub 2019 Oct 16.
For patients undergoing percutaneous coronary intervention, gene-drug associations exist relevant to first-line treatment options-antiplatelet agent, clopidogrel, and pain medication, tramadol. Knowledge of genotype information may allow for avoidance of adverse drug events during critical clinical windows.
This evaluation estimated cost-effectiveness associated with a multi-gene panel pre-emptively testing two genes providing CYP2C19 genotype-guided strategy for antiplatelet therapy, with CYP2D6 genotype-guided pain management, compared to single gene test for CYP2C19 with random assignment for pain treatment, and to no testing (empiric clopidogrel with random assignment for pain treatment).
Decision analysis modeling was used to project costs from a payer perspective and patient quality-adjusted life years (QALYs) from the three strategies. The model captured composite risks of major adverse cardiovascular events and pain therapy-related adverse drug events and associated utility estimates. We conducted sensitivity analyses to assess influential input parameters.
Over 15 months, multi-gene testing was least costly and yielded more QALYs compared to both single gene and no testing; total incremental costs were $1646 lower with incremental gains of 0.04 QALYs for multi-gene compared with single gene and $11 368 lower with 0.17 QALY gains compared to no test. Base case analyses revealed multi gene was dominant compared to both single gene and no test, as it demonstrated cost savings with increased QALYs.
For these patients, a multi-gene-guided strategy yields a favorable incremental cost-effectiveness ratio compared to the other two treatment strategies. Pre-emptively ascertaining additional gene-drug pair information can inform clinical and economic decision-making at the point of care.
对于接受经皮冠状动脉介入治疗的患者，存在与一线治疗选择（抗血小板药物氯吡格雷和镇痛药物曲马多）相关的基因-药物关联。了解基因型信息可能有助于在关键临床窗口期避免药物不良事件。
本评估估计了与多基因检测相关的成本效益，该检测预先检测两个基因，为抗血小板治疗提供 CYP2C19 基因型指导策略，为疼痛管理提供 CYP2D6 基因型指导，与 CYP2C19 的单基因检测和随机分配的疼痛治疗相比，以及与不进行检测（经验性氯吡格雷随机分配用于疼痛治疗）相比。
决策分析模型用于从支付者角度预测成本，并从三个策略的角度预测患者质量调整生命年（QALY）。该模型捕获了主要不良心血管事件和疼痛治疗相关药物不良事件的复合风险以及相关的效用估计。我们进行了敏感性分析以评估有影响的输入参数。
在 15 个月内，与单基因和不进行检测相比，多基因检测的成本最低，QALYs 更高；与单基因相比，多基因检测的增量成本低 1646 美元，增量 QALY 增加 0.04；与不进行检测相比，增量成本低 11368 美元，增量 QALY 增加 0.17。基本情况分析表明，多基因检测与单基因和不进行检测相比具有优势，因为它在增加 QALYs 的同时实现了成本节约。
对于这些患者，与其他两种治疗策略相比，多基因指导策略具有有利的增量成本效益比。预先确定额外的基因-药物对信息可以为护理点的临床和经济决策提供信息。
