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The Comparative Effectiveness, Safety, Value, and Adherence of Newer P2Y12 Inhibitors versus Clopidogrel in the Context of Heterogeneity
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| 자료유형 | 학위논문 |
|---|---|
| 서명/저자사항 | The Comparative Effectiveness, Safety, Value, and Adherence of Newer P2Y12 Inhibitors versus Clopidogrel in the Context of Heterogeneity. |
| 개인저자 | Suh, Kangho. |
| 단체저자명 | University of Washington. Pharmacy. |
| 발행사항 | [S.l.]: University of Washington., 2019. |
| 발행사항 | Ann Arbor: ProQuest Dissertations & Theses, 2019. |
| 형태사항 | 100 p. |
| 기본자료 저록 | Dissertations Abstracts International 81-04B. Dissertation Abstract International |
| ISBN | 9781687956392 |
| 학위논문주기 | Thesis (Ph.D.)--University of Washington, 2019. |
| 일반주기 |
Source: Dissertations Abstracts International, Volume: 81-04, Section: B.
Advisor: Basu, Anirban. |
| 이용제한사항 | This item must not be sold to any third party vendors.This item must not be added to any third party search indexes. |
| 요약 | BackgroundP2Y12 inhibitors are a class of medications indicated with aspirin as part of dual antiplatelet therapy (DAPT) for patients with acute coronary syndrome after undergoing percutaneous coronary intervention (PCI). Taking a P2Y12 inhibitor along with aspirin after PCI reduces the incidence of cardiovascular death, nonfatal MI, and stroke in the following year. Clopidogrel, the first oral P2Y12 inhibitor, was approved in 1997 and was used widely as part of DAPT therapy. However, there are some issues with clopidogrel such as low bioavailability and slow onset of platelet inhibition compared to newer agents, heterogeneity in patient response, and drug resistance. These concerns were addressed with two newer oral agents, prasugrel and ticagrelor, which were approved in 2009 and 2011, respectively. This study aims to examine the heterogeneity in treatment effects of these antiplatelet agents and assess how healthcare providers and patients change their behaviors as a result. In Aim 1, I examined whether physicians identify heterogeneity of treatment effects (HTE) with P2Y12 inhibitors and change their prescribing patterns as a result. This is extended into Aim 2, which explored whether physicians' adaptions in prescribing patterns was a cost effective strategy. Aim 3 assessed patients' adherence to P2Y12 inhibitors and determined if any factors were associated with heterogenous impacts along the adherence distribution. MethodsIn Aim 1, an instrumental variable approach with person-centered treatment effects was used to assess patient-level comparative effectiveness and safety outcomes from January 2010 to December 2017. These outcomes were used to study whether physician adapted their prescribing patterns over the study period to match the most optimal P2Y12 inhibitor with the patient. In Aim 2, results from Aim 1 were extended to develop a hybrid lifetime Markov model to assess whether physicians' adaptive prescribing with P2Y12 inhibitors was a cost effective strategy compared to universal treatment with clopidogrel or the newer P2Y12 inhibitors. Inputs for the 1-year short term model were informed from Aim 1 results, while inputs for the lifetime model were informed from the literature. In Aim 3, conditional and unconditional quantile regression models were used along with more traditional logistic regression models to examine medication adherence of the three P2Y12 inhibitor, and to determine which covariates had heterogenous impacts along the adherence distribution. Patients who received drug eluting stents were measured for 185 days.ResultsIn Aim 1, 52,823 patients were included for analysis. Patients on ticagrelor and prasugrel had a significantly lower probability of major adverse cardiovascular events [-3.97 percentage points (95% CI, -6.97 to -0.26)] and significantly lower probability of major bleeding events [-2.93 percentage points (95% CI, -4.83 to -0.70)] compared to patients on clopidogrel. Physicians were able to better align patients who would benefit on clopidogrel from 17.39% in 2010 to 26.40% by 2015, but patient outcomes were not significantly different than when everyone received ticagrelor or prasugrel. In Aim 2, physicians' adaptive prescribing resulted in 11.63 life-years (LYs), 9.92 quality-adjusted life-years (QALYs), and $72,403 total costs |
| 일반주제명 | Pharmaceutical sciences. |
| 언어 | 영어 |
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