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Communications to the Editor |

Enoxaparin Treatment in Unstable Coronary Artery Disease : International Cost Savings FREE TO VIEW

Keith A. A. Fox, MB ChB, FRCP; Shaun G. Goodman, MD
Author and Funding Information

Affiliations: Royal Infirmary of Edinburgh Edinburgh, UK St. Michael’s Hospital Toronto, Canada,  *University of British Columbia Vancouver, British Columbia* Montreal Heart Institute Montreal, Quebec

Correspondence to: Keith A. A. Fox, MB ChB, FRCP, Department of Cardiology, Royal Infirmary of Edinburgh, Lauriston Place, Edinburgh, EH3 9YW, UK; e-mail: k.a.a.fox@ed.ac.uk



Chest. 2002;121(2):666-667. doi:10.1378/chest.121.2.666
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Published online

To the Editor:

We wish to challenge the statement in the review of antithrombotic agents for use in coronary artery disease by Cairns et al1 that, compared with unfractionated heparin, the treatment of unstable coronary artery disease with enoxaparin produces significant cost savings only in hospitals in the United States and not in the hospitals of other countries. In fact, a number of peer-reviewed articles have demonstrated that treatment of this condition with enoxaparin produces significant cost savings in hospitals in countries other than the United States, including Canada, South America, the United Kingdom, and France.

Based on the Efficacy and Safety of Subcutaneous Enoxaparin in Non-Q-Wave Coronary Events (ESSENCE) trial,2use of enoxaparin instead of unfractionated heparin resulted in a significant in-hospital and 30-day cost saving in US patients (Table 1 ).3 Similar results were seen at 30 days in the French4and Argentina/Uruguay5subgroups of the ESSENCE trial. Further, a Canadian predictive decision-analysis model confirmed that enoxaparin was the least costly strategy for the majority of 30-day composite end point values.6Finally, based in part on the continued advantage of enoxaparin over unfractionated heparin at 1 year follow-up,7both UK8and Canadian9cost-effectiveness analyses predicted impressive cost savings with enoxaparin. Thus, in addition to greater clinical efficacy observed in the ESSENCE trial and recently confirmed in other studies,1012 use of enoxaparin led to both lower administrative costs (less use of IV sets, IV infusion pumps, and nursing time) and decreased resource utilization (fewer cardiac catheterizations, coronary revascularizations, shorter length of hospital stay). Despite the modestly higher drug acquisition cost, these advantages translated into observed cost savings with enoxaparin as compared to unfractionated heparin in several different countries. In addition, it should be noted that all the studies mentioned have only considered direct costs and have not included indirect costs (such as loss of work time, and increased costs incurred by patients), and thus it is possible to speculate on further savings to society were these costs analyzed.

The consistent results from these analyses lead us to conclude that the treatment of unstable coronary artery disease with enoxaparin is less costly than treatment with unfractionated heparin, not only in the United States but also other clinical practice settings and countries in the world. We suggest that an erratum should be published, and that the results from these studies should be considered when the American College of Chest Physician guidelines for antithrombotic therapy are next updated.

Table Graphic Jump Location
Table 1. Overview of Cost Savings Observed in Health Economic Analyses of the ESSENCE Trial
* 

Currency converted using Economic Times (US) data, May 29, 2001.

Cairns, JA, Théroux, P, Lewis, HD, et al (2001) Antithrombotic agents in coronary artery disease.Chest119,228S-252S. [PubMed] [CrossRef]
 
Cohen, M, Demers, C, Gurfinkel, EP, et al A comparison of low-molecular-weight heparin with unfractionated heparin for unstable coronary artery disease: Efficacy and Safety of Subcutaneous Enoxaparin in Non-Q-Wave Coronary Events Study Group.N Engl J Med1997;337,447-452. [PubMed]
 
Mark, DB, Cowper, PA, Berkowitz, SD, et al Economic assessment of low-molecular weight heparin (enoxaparin) versus unfractionated heparin in acute coronary syndrome patients: results from the ESSENCE randomized trial.Circulation1998;97,1702-1707. [PubMed]
 
Detournay, B, Huet, X, Fagnani, F, et al Economic evaluation of enoxaparin sodium versus heparin in unstable angina: a French sub-study of the ESSENCE trial.Pharmacoeconomics2000;18,83-89. [PubMed]
 
Bozovich, G, Gurfinkel, E, Barreiro, D, et al Reduction of hospital costs for patients with acute non-Q-wave myocardial infarction or unstable angina treated with enoxaparin compared to standard heparin [abstract]. Eur Heart J. 1999;;20 ,.:545
 
Balen, RM, Marra, CA, Zed, PJ, et al Cost-effectiveness analysis of enoxaparin versus unfractionated heparin for acute coronary syndromes: a Canadian hospital perspective.Pharmacoeconomics1999;16(5 pt 2),533-542
 
Goodman, S, Cohen, M, Bigonzi, F, et al Randomised trial of low molecular weight heparin (enoxaparin) versus unfractionated heparin for unstable coronary artery disease: one year results of the ESSENCE study.J Am Coll Cardiol2000;36,693-698. [PubMed]
 
Bosanquet, N, Fox, KAA Longer term economic benefits reflect improved clinical outcomes with enoxaparin versus unfractionated heparin in acute coronary syndromes: one-year data.Br J Cardiol2001;8,36-37
 
O’Brien, BJ, Willan, A, Blackhouse, G, et al Will the use of low-molecular-weight heparin (enoxaparin) in patients with acute coronary syndrome save costs in Canada?Am Heart J2000;139,423-429. [PubMed]
 
Antman, E, McCabe, CH, Gurfinkel, EP, et al Enoxaparin prevents death and cardiac ischemic events in unstable angina/non-Q-wave myocardial infarction: results of the Thrombolysis in Myocardial Infarction (TIMI) 11B Trial.Circulation1999;100,1593-1601. [PubMed]
 
Antman, EM, Cohen, M, Radley, D, et al Assessment of the treatment effect of enoxaparin for unstable angina/non-Q-wave myocardial infarction: TIMI 11B-ESSENCE meta-analysis.Circulation1999;100,1602-1608. [PubMed]
 
Antman EM, Cohen M, McCabe C, et al. Enoxaparin is superior to unfractionated heparin for preventing clinical events at 1-year follow-up of TIMI 11B and ESSENCE. Eur Heart J Ideal First Articles 2001. Available at: http://www. idealibrary.com/links/doi/10.1053/euhj.2001.2779. Accessed January 3, 2002.
 
To the Editor:

The study of Mark et al1 was based on the 655 US patients with available economic data, out of the total of 936 US patients in the Efficacy and Safety of Subcutaneous Enoxaporin in Non-Q-Wave Coronary Events (ESSENCE) trial. The overall cost reduction associated with enoxaparin use was statistically significant at 30 days among the US patients. Amongst the total study cohort, there was a trend toward reduced costs, but it was not statistically significant. These data underlay our statement that “an economic assessment of the ESSENCE results showed significant cost savings in US hospitals, but not across those in other countries with the cost saving mainly attributable to fewer cardiac catherization procedures.”

Fox and Goodman, in their letter, refer to economic analyses of non-US national subpopulations drawn from the ESSENCE trial, the results of which are consistent with the nonsignificant trend toward cost savings with enoxaparin use reported in the article to which we referred.1 Although the outcome data for the TIMI 11B trial (references 10, 11, and 12 in their letter all relate to this trial) are similar to those in the ESSENCE trial, we are not aware of any published procedural data or economic analyses based on this trial.

References
Mark, DB, Cowper, PA, Berkowitz, SD, et al Economic assessment of low molecular weight heparin (enoxaparin) versus unfractionated heparin in acute coronary syndrome patients: results from the ESSENCE randomized trial. Efficacy and Safety of Subcutaneous Enoxaparin in Non-Q-wave Coronary Events (unstable angina or non-Q-wave myocardial infarction).Circulation1998;97,1702-1707. [PubMed] [CrossRef]
 

Figures

Tables

Table Graphic Jump Location
Table 1. Overview of Cost Savings Observed in Health Economic Analyses of the ESSENCE Trial
* 

Currency converted using Economic Times (US) data, May 29, 2001.

References

Cairns, JA, Théroux, P, Lewis, HD, et al (2001) Antithrombotic agents in coronary artery disease.Chest119,228S-252S. [PubMed] [CrossRef]
 
Cohen, M, Demers, C, Gurfinkel, EP, et al A comparison of low-molecular-weight heparin with unfractionated heparin for unstable coronary artery disease: Efficacy and Safety of Subcutaneous Enoxaparin in Non-Q-Wave Coronary Events Study Group.N Engl J Med1997;337,447-452. [PubMed]
 
Mark, DB, Cowper, PA, Berkowitz, SD, et al Economic assessment of low-molecular weight heparin (enoxaparin) versus unfractionated heparin in acute coronary syndrome patients: results from the ESSENCE randomized trial.Circulation1998;97,1702-1707. [PubMed]
 
Detournay, B, Huet, X, Fagnani, F, et al Economic evaluation of enoxaparin sodium versus heparin in unstable angina: a French sub-study of the ESSENCE trial.Pharmacoeconomics2000;18,83-89. [PubMed]
 
Bozovich, G, Gurfinkel, E, Barreiro, D, et al Reduction of hospital costs for patients with acute non-Q-wave myocardial infarction or unstable angina treated with enoxaparin compared to standard heparin [abstract]. Eur Heart J. 1999;;20 ,.:545
 
Balen, RM, Marra, CA, Zed, PJ, et al Cost-effectiveness analysis of enoxaparin versus unfractionated heparin for acute coronary syndromes: a Canadian hospital perspective.Pharmacoeconomics1999;16(5 pt 2),533-542
 
Goodman, S, Cohen, M, Bigonzi, F, et al Randomised trial of low molecular weight heparin (enoxaparin) versus unfractionated heparin for unstable coronary artery disease: one year results of the ESSENCE study.J Am Coll Cardiol2000;36,693-698. [PubMed]
 
Bosanquet, N, Fox, KAA Longer term economic benefits reflect improved clinical outcomes with enoxaparin versus unfractionated heparin in acute coronary syndromes: one-year data.Br J Cardiol2001;8,36-37
 
O’Brien, BJ, Willan, A, Blackhouse, G, et al Will the use of low-molecular-weight heparin (enoxaparin) in patients with acute coronary syndrome save costs in Canada?Am Heart J2000;139,423-429. [PubMed]
 
Antman, E, McCabe, CH, Gurfinkel, EP, et al Enoxaparin prevents death and cardiac ischemic events in unstable angina/non-Q-wave myocardial infarction: results of the Thrombolysis in Myocardial Infarction (TIMI) 11B Trial.Circulation1999;100,1593-1601. [PubMed]
 
Antman, EM, Cohen, M, Radley, D, et al Assessment of the treatment effect of enoxaparin for unstable angina/non-Q-wave myocardial infarction: TIMI 11B-ESSENCE meta-analysis.Circulation1999;100,1602-1608. [PubMed]
 
Antman EM, Cohen M, McCabe C, et al. Enoxaparin is superior to unfractionated heparin for preventing clinical events at 1-year follow-up of TIMI 11B and ESSENCE. Eur Heart J Ideal First Articles 2001. Available at: http://www. idealibrary.com/links/doi/10.1053/euhj.2001.2779. Accessed January 3, 2002.
 
Mark, DB, Cowper, PA, Berkowitz, SD, et al Economic assessment of low molecular weight heparin (enoxaparin) versus unfractionated heparin in acute coronary syndrome patients: results from the ESSENCE randomized trial. Efficacy and Safety of Subcutaneous Enoxaparin in Non-Q-wave Coronary Events (unstable angina or non-Q-wave myocardial infarction).Circulation1998;97,1702-1707. [PubMed] [CrossRef]
 
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