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Cost-effectiveness of measuring fractional flow reserve to guide coronary interventions
William F Fearon1, Alan C Yeung, David P Lee
1Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford, Calif 94305-5406, USA. wfearon@stanford.edu
Insights
Measuring fractional flow reserve (FFR) is more cost-effective for intermediate coronary lesions than nuclear imaging or stenting all lesions. This approach offers significant savings for patients needing treatment without prior functional tests.
Area of Science:
- Cardiology
- Interventional Cardiology
- Health Economics
Background:
- Patients often lack pre-procedure functional tests for intermediate coronary lesions.
- This presents a challenge for cost-effective treatment decisions in the catheterization laboratory.
Purpose of the Study:
- To compare the long-term costs and benefits of three strategies for treating intermediate coronary lesions without prior functional studies.
- To evaluate the economic and clinical outcomes of nuclear imaging, fractional flow reserve (FFR) measurement, and routine stenting.
Main Methods:
- A decision model was developed to compare nuclear stress imaging (NUC), fractional flow reserve (FFR), and stenting (STENT) strategies.
- Model inputs included estimated ischemia rates, angina-free rates, quality-of-life adjustments, and costs of procedures and medical treatment.
- Sensitivity and threshold analyses were performed to assess the impact of variable changes.
Main Results:
- The FFR strategy demonstrated cost savings of $1795/patient vs. NUC and $3830/patient vs. STENT.
- Quality-adjusted life expectancy was similar across strategies, but NUC was significantly more expensive per quality-adjusted life year gained compared to FFR.
- Both FFR and NUC screening strategies were superior to the STENT strategy in terms of cost and outcomes.
Conclusions:
- Measuring FFR to guide percutaneous coronary intervention (PCI) decisions in patients with intermediate coronary lesions is cost-effective.
- FFR measurement offers significant cost savings compared to nuclear stress imaging or routine stenting.
- This strategy optimizes treatment decisions for patients presenting without prior functional assessment.
Background:
Most patients come to the catheterization laboratory without prior functional tests, which makes the cost-effective treatment of patients with intermediate coronary lesions a practical challenge.
Methods:
We developed a decision model to compare the long-term costs and benefits of 3 strategies for treating patients with an intermediate coronary lesion and no prior functional study: 1) deferring the decision for percutaneous coronary intervention (PCI) to obtain a nuclear stress imaging study (NUC strategy); 2) measuring fractional flow reserve (FFR) at the time of angiography to help guide the decision for PCI (FFR strategy); and 3) stenting all intermediate lesions (STENT strategy). On the basis of the literature, we estimated that 40% of intermediate lesions would produce ischemia, 70% of patients treated with PCI and 30% of patients treated medically would be free of angina after 4 years, and the quality-of-life adjustment for living with angina was 0.9 (1.0 = perfect health). We estimated the cost of FFR to be 761 dollars, the cost of nuclear stress imaging to be 1093 dollars, and the cost of medical treatment for angina to be 1775 dollars per year. The extra cost of splitting the angiogram and PCI as dictated by the NUC strategy was 3886 dollars by use of hospital cost-accounting data. Sensitivity and threshold analyses were performed to determine which variables affected our results.
Results:
The FFR strategy saved 1795 dollars per patient compared with the NUC strategy and 3830 dollars compared with the STENT strategy. Quality-adjusted life expectancy was similar among the 3 strategies (NUC-FFR = 0.8 quality-adjusted days, FFR-STENT = 6 quality-adjusted life days). Compared with the FFR strategy, the NUC strategy was expensive (>800,000 dollars per quality-adjusted life year gained). Both screening strategies were superior to (less cost, better outcomes) the STENT strategy. Sensitivity analysis indicated that the NUC strategy would only become attractive (<50,000 dollars/quality-adjusted life years compared with FFR) if the specificity of nuclear stress imaging was >25% better than FFR. Our results were not altered significantly by changing the other assumptions.
Conclusion:
In patients with an intermediate coronary lesion and no prior functional study, measuring FFR to guide the decision to perform PCI may lead to significant cost savings compared with performing nuclear stress imaging or with simply stenting lesions in all patients.