Economic Assessment of Low-Molecular-Weight Heparin (Enoxaparin) Versus Unfractionated Heparin in Acute Coronary Syndrome Patients Results From the ESSENCE Randomized Trial

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 (R5.86). 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, P5.04). At 30 days, these effects persisted, with the largest reductions seen in diagnostic catheterization (57% versus 63% for heparin, P5.04) and coronary angioplasty (18% versus 22%, P5.08). 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 (P5.18). At the end of 30 days, the cumulative cost savings associated with enoxaparin was $1172 (P5.04). 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. (Circulation. 1998;97:1702-1707.)