Date of Award

January 2025

Document Type

Open Access Thesis

Degree Name

Master of Public Health (MPH)

Department

School of Public Health

First Advisor

Cassius Iyad Ochoa Chaar

Second Advisor

Ira L. Leeds

Abstract

Introduction and Objective: Antithrombotic treatment plays a critical role in managingperipheral arterial disease (PAD) and reducing the risk of major adverse limb events (MALE) and major adverse cardiovascular events (MACE) after revascularization. Dual antiplatelet therapy (DAPT) with aspirin and clopidogrel is the most commonly used regimen for medical management to prevent cardiovascular events following revascularization. Still, emerging studies suggest that dual antithrombotic pathway inhibition (DAPI), which combines a Factor Xa inhibitor with clopidogrel, may offer enhanced protection. This study evaluates the clinical outcomes and cost-effectiveness of DAPI compared to DAPT in patients undergoing lower extremity revascularization (LER).

Methods: A retrospective cohort analysis was conducted on patients who underwent open orendovascular LER at a tertiary healthcare institution. After applying a 4:1 propensity score matching (PSM), patient characteristics and outcomes of those discharged on DAPT and DAPI were compared. Cost-effectiveness was evaluated over a five-year horizon using modeled costs and quality-adjusted life years (QALYs), and the incremental cost-effectiveness ratio (ICER) was calculated. The willingness-to-pay threshold (WTP) was set at $150,000 per QALY, which aligns with the average United States WTP for health interventions.

Results: Of 986 patients who underwent LER, 95.5% received DAPT and 5.6% received DAPI.The DAPI cohort was older but had significantly lower rates of MALE and lower rates of the composite outcome of MACE and MALE. After PSM, Kaplan-Meier analysis showed significantly improved MALE-free survival in the DAPI group, while MACE-free survival was comparable between the two cohorts. Though the DAPI strategy incurred higher costs ($73,826 vs. $39,548), it yielded greater health benefits (4.64 vs. 3.51 QALYs), resulting in an ICER of $30,331 per QALY, indicating it is a cost-effective intervention compared to DAPT.

Conclusions: DAPI is associated with superior limb-related outcomes and represents a cost-effective alternative to DAPT for antithrombotic management post-revascularization.

Comments

This is an Open Access Thesis.

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