Supplementary Online Content

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1 Supplementary Online Content Earnshaw SR, Scheiman J, Fendrick AM, McDade C, Pignone M. Cost-utility of aspirin and proton pump inhibitors for primary prevention. Arch Intern Med. 0;7():8-5. eappendix. Supplementary cost-effectiveness analysis ereferences etable. Cost and Utility Parameters, Values, and Plausible Ranges etable. Diagnostic performance of serological tests test combinations efigure. Model Structure efigure. Sensitivity Analysis: Effect of Change in Baseline Gastrointestinal Bleed Risk for a 55-Year-Old Man With a 0-Year, 0% CHD Risk. A. Aspirin Versus No Treatment. B. Aspirin+PPI Versus Aspirin Alone efigure. Sensitivity Analysis: Effect of Change in Baseline Gastrointestinal Bleed Risk for a 65-Year-Old Man With a 0-Year, 0% CHD Risk. A. Aspirin Versus No Treatment. B. Aspirin+PPI Versus Aspirin Alone efigure. Sensitivity Analysis: Effect of Change in Risk of Gastrointestinal Bleed Mortality for a 5-Year-Old Man With a 0-Year, 0% CHD Risk Aspirin+PPI Versus Aspirin Alone efigure 5. Sensitivity Analysis: Effect of Change in Annual Price of PPI for a 5-Year-Old Man With a 0-Year, 0% CHD Risk Aspirin+PPI Versus Aspirin Alone efigure 6. Probabilistic Sensitivity Analysis: a 5-Year-Old Man With a 0-Year, 0% CHD Risk Aspirin Versus No Treatment Cost-effectiveness Acceptability Curve efigure 7. Probabilistic Sensitivity Analysis: a 65-Year-Old Man With a 0-Year, 0% CHD Risk Aspirin Versus No Treatment. A: Scatter Plot. B. Cost-effectiveness Acceptability Curve efigure 8. Probabilistic Sensitivity Analysis: a 65-Year-Old Man With a 0-Year, 0% CHD Risk Aspirin+PPI Versus Aspirin Alone This supplementary material has been provided by the authors to give readers additional information about their work. 00 American Medical Association. All rights reserved. Downloaded From: on 0/07/09

2 eappendix Costs Healthy men with and without previous gastrointestinal bleed incurred one outpatient physician visit per year. Acute event health states (angina, myocardial infarction, stroke, and gastrointestinal bleed) included the cost of hospitalization for the respective event as estimated from Healthcare Cost and Utilization Project, Nationwide Inpatient Sample, which contains a national representative sample of hospital inpatient stays. The Healthcare Cost and Utilization Project, Nationwide Inpatient Sample is compiled by the Agency for Healthcare Research and Quality and contains a national representative sample of hospital inpatient stays for a variety of International Classification of Diseases 9th Revision, Clinical Modification and Healthcare Common Procedure Coding System codes. Men in these health states incurred one annual outpatient physician visit and post-event costs for the remaining months within the health state. Annual costs for post-event health states (post angina, post myocardial infarction, and post stoke) were obtained from published literature. Once a man had a cardiovascular disease event, he was assumed to have four additional visits a year. Cost of generic aspirin (8 mg per day) and omeprazole (0 mg per day) were estimated from publicly available drug store pricing ( Details on costs are presented in etable. Utilities The utilities for the model were drawn from the literature and are shown in etable. -6 Results Results are presented in etable and efigures through 8. Acceptability curves for aspirin +PPI versus aspirin alone were not shown for 5 year old and 65 year men because no incremental costeffectiveness ratios between 0 and $50,000 were generated as within the probabilistic sensitivity analyses. 00 American Medical Association. All rights reserved. Downloaded From: on 0/07/09

3 REFERENCES. Pignone M, Earnshaw S, Pletcher MJ, et al. Aspirin for the primary prevention of cardiovascular disease in women. Arch Intern Med. 007;67: Augustovski FA, Cantor SB, Thach CT, Spann, SJ. Aspirin for primary prevention of cardiovascular events. J Gen Intern Med. 998;: Spiegel BM, Chiou CF, Ofman JJ. Minimizing complications from nonsteroidal antiinflammatory drugs: cost-effectiveness of competing strategies in varying risk. Arthritis Rheum. 005;5(): Nease RF, Kneeland T, O Connor GT, et al. Variation in patient utilities for outcomes of the management of chronic stable angina. JAMA. 995;7: Gore JM, Granger CB, Simoons ML, et al. Stroke after thrombolysis: mortality and functional outcomes in the GUSTO-I trial. Circulation. 995;9: Tsevat J, Goldman L, Soukup JR, et al. Stability of time-tradeoff utilities in survivors of myocardial infarction. Med Decis Making. 99;: Walgreen s. Aspirin pricing Available at: Accessed September 6, American Medical Association (AMA). Current procedural terminology. CPT 00. Chicago, IL: AMA Press; Ingenix, Inc. The essential RBRVS: a comprehensive listing of RBRVS values for CPT and HCPCS codes. St. Anthony Publishing; HCUPnet. Healthcare Cost and Utilization Project (HCUP). Rockville, MD: Agency for Healthcare Research and Quality; 006. Available at: Accessed June 7, American Medical Association. All rights reserved. Downloaded From: on 0/07/09

4 Friedman B, La Mare J, Andrews R, et al. Assuming an average cost to charge ratio of 0.5: practical options for estimating cost of hospital inpatient stays. J Health Care Finance. 00;9:-.. US Dept of Labor, US Bureau of Labor Statistics. US city average, not seasonally adjusted medical care. Available at: Accessed April 0, Russell MW, Huse DM, Drowns S, et al. Direct medical costs of coronary artery disease in the United States. Am J Cardiol. 998;8: etable. Cost and Utility Parameters, Values, and Plausible Ranges Parameter Cost Data (annual) Base-Case Value (Range) Source or Assumption Aspirin $.99 8 mg daily 7 Generic PPI $ mg of omeprazole daily 7 Outpatient physician visit $6.76 CPT code 990 8,9 Health State Costs (Annual) Healthy $6.76 Assumed to be outpatient physician visit a year 00 American Medical Association. All rights reserved. Downloaded From: on 0/07/09

5 Gastrointestinal bleed $, Gastrointestinal bleed ICD-9 codes: 5.00, 5.0, 5.0, 5., 5.00, 5.0, 5.0, 5., 5.00, 5.0, 5.0, 5., 5.00, 5.0, 5.0, 5., 55.0, 55., 55., 55., 55., 55.5, Post gastrointestinal bleed $6.76 Assumed to similar to healthy patient 00 American Medical Association. All rights reserved. 5 Downloaded From: on 0/07/09

6 etable (continued). Cost and Utility Parameters, Values, and Plausible Ranges Parameter Base-Case Value (Range) Source or Assumption Angina $,7 Angina ICD-9 codes:.9 0- Post angina $5,99, Stroke $,706 Stroke ICD-9 codes: 0.xx,.xx,.0,.,.,.,.,.5,.6,.7,.8,.9,.0,.,.,.,.5,.6,.7,.8,.9, 6.xx 0- Post stroke $,85, Myocardial infarction $,65 Myocardial infarction ICD-9 codes: 0.xx 0- Post myocardial infarction $,590, 00 American Medical Association. All rights reserved. 6 Downloaded From: on 0/07/09

7 etable (continued). Cost and Utility Parameters, Values, and Plausible Ranges Parameter Utility Data Base-Case Value (Range) Source or Assumption Healthy.000 Gastrointestinal bleed 0.9 (95% CI: 0.880,.000) Post gastrointestinal bleed.000 Assumption Dyspepsia Angina Post angina Stroke (95% CI: 0.997,.000) 0.99 (95% CI: 0.9,.000) (95% CI: 0.997,.000) 0.60 (95% CI: 0.80, 0.80) Post stroke Myocardial infarction Post myocardial infarction (95% CI: 0.80, 0.90) 0.90 (95% CI: 0.860, 0.960) 6 6 Healthy.000 CI = confidence interval; CPT = current procedural terminology; HCUP = Healthcare Cost and Utilization Project; ICD-9 = International Classification of Diseases, 9th Revision, Clinical Modification; PPI = proton pump inhibitor. 00 American Medical Association. All rights reserved. 7 Downloaded From: on 0/07/09

8 etable. Effect of 0-Year CHD Risk on Lifetime Cost-Utility Ratio for 5-Year-Old Men Using Risk of MI and Stroke From Berger et al. (006) High- Low Low-Moderate Moderate Moderate High Very High (.5%) Risk (5.0%) Risk (7.5%) Risk (0%) Risk (5%) Risk (5%) Risk Results for 5-Year-Old Men Aspirin vs. no $7,008 More effective, More effective, More effective, More effective, More effective, treatment less costly less costly less costly less costly less costly Aspirin+PPI vs. $89,707 $68,688 $99,0 $9,567 $67,7 $,556 aspirin alone Results for 65-Year-Old Men Aspirin vs. no treatment $,977 $,9 $5 More effective, less costly More effective, less costly Aspirin+PPI vs. $8, $,6 $8,85 $8,09 $77,7 aspirin alone CHD = coronary heart disease; PPI = proton pump inhibitor American Medical Association. All rights reserved. Downloaded From: on 0/07/09

9 efigure. Model Structure a a Men can progress from any health state to death. 9 Downloaded From: on 0/07/09

10 efigure. Sensitivity Analysis: Effect of Change in Baseline Gastrointestinal Bleed Risk for a 55-Year-Old Man With a 0-Year, 0% CHD Risk efigure A. Aspirin Versus No Treatment 0 Downloaded From: on 0/07/09

11 efigure B. Aspirin+PPI Versus Aspirin Alone CHD = coronary heart disease; PPI = proton pump inhibitor; QALY = quality-adjusted life-year. Downloaded From: on 0/07/09

12 efigure. Sensitivity Analysis: Effect of Change in Baseline Gastrointestinal Bleed Risk for a 65-Year-Old Man With a 0-Year, 0% CHD Risk efigure A. Aspirin Versus No Treatment Downloaded From: on 0/07/09

13 efigure B. Aspirin+PPI Versus Aspirin Alone CHD = coronary heart disease; PPI = proton pump inhibitor; QALY = quality-adjusted life-year. Downloaded From: on 0/07/09

14 efigure. Sensitivity Analysis: Effect of Change in Risk of Gastrointestinal Bleed Mortality for a 5-Year-Old Man With a 0-Year, 0% CHD Risk Aspirin+PPI Versus Aspirin Alone 5 CHD = coronary heart disease; PPI = proton pump inhibitor; QALY = quality-adjusted life-year. Downloaded From: on 0/07/09

15 efigure 5. Sensitivity Analysis: Effect of Change in Annual Price of PPI for a 5- Year-Old Man With a 0-Year, 0% CHD Risk Aspirin+PPI Versus Aspirin Alone CHD = coronary heart disease; PPI = proton pump inhibitor; QALY = quality-adjusted life-year. 5 Downloaded From: on 0/07/09

16 efigure 6. Probabilistic Sensitivity Analysis: a 5-Year-Old Man With a 0-Year, 0% CHD Risk Aspirin Versus No Treatment Cost-effectiveness Acceptability Curve CHD = coronary heart disease; QALY = quality-adjusted life-year. 6 Downloaded From: on 0/07/09

17 efigure 7. Probabilistic Sensitivity Analysis: a 65-Year-Old Man With a 0-Year, 0% CHD Risk Aspirin Versus No Treatment efigure 7A: Scatter Plot 5 7 Downloaded From: on 0/07/09

18 efigure 7B. Cost-effectiveness Acceptability Curve CHD = coronary heart disease; QALY = quality-adjusted life-year. 8 Downloaded From: on 0/07/09

19 efigure 8. Probabilistic Sensitivity Analysis: a 65-Year-Old Man With a 0-Year, 0% CHD Risk Aspirin+PPI Versus Aspirin Alone 5 9 Downloaded From: on 0/07/09