From the Outcomes Research and Assessment Group, Clinical Research
Institute; the Division of Cardiology, Department of Medicine; and the
Division of Biometry, Department of Community and Family Medicine, Duke
University Medical Center, Durham, NC.
Correspondence to Daniel B. Mark, MD, MPH, Box 3485, Duke University Medical Center, Durham, NC 27710. E-mail mark0004{at}onyx.mc.duke.edu
Background—In the ESSENCE trial,
subcutaneous low-molecular-weight heparin (enoxaparin) reduced the
30-day incidence of death, myocardial infarction, and recurrent angina
relative to intravenous unfractionated heparin in 3171
patients with acute coronary syndrome (unstable angina or
non–Q-wave myocardial infarction). No increase in major bleeding
was seen.
Methods and Results—Of the 936 ESSENCE patients randomized in the
United States, 655 had hospital billing data collected. For the
remainder, hospital costs were imputed with a multivariable linear
regression model (R2=.86). Physician fees
were estimated from the Medicare Fee Schedule. During the initial
hospitalization, major resource use was reduced for enoxaparin
patients, with the largest effect seen with coronary
angioplasty (15% versus 20% for heparin, P=.04). At 30
days, these effects persisted, with the largest reductions seen in
diagnostic catheterization (57% versus
63% for heparin, P=.04) and coronary
angioplasty (18% versus 22%, P=.08). All resource use
trends seen in the US cohort were also evident in the overall ESSENCE
study population. In the United States, the mean cost of a course of
enoxaparin therapy was $155, whereas that for heparin was $80. The
total medical costs (hospital, physician, drug) for the initial
hospitalization were $11 857 for enoxaparin and $12 620 for heparin,
a cost advantage for the enoxaparin arm of $763 (P=.18).
At the end of 30 days, the cumulative cost savings associated with
enoxaparin was $1172 (P=.04). In 200 bootstrap samples
of the 30-day data, 94% of the samples showed a cost advantage for
enoxaparin.
Conclusions—In patients with acute coronary syndrome,
low-molecular-weight heparin (enoxaparin) both improves important
clinical outcomes and saves money relative to therapy with standard
unfractionated heparin.
© 1998 American Heart Association, Inc.
Clinical Investigation and Reports
Economic Assessment of Low-Molecular-Weight Heparin (Enoxaparin) Versus Unfractionated Heparin in Acute Coronary Syndrome Patients
Results From the ESSENCE Randomized Trial
Key Words: anticoagulants • angina • coronary disease • cost-benefit analysis
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