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Medical therapy v. PCI in stable coronary artery disease: a cost-effectiveness analysis
Harindra C Wijeysundera1,2,3,4, George Tomlinson2,3,4, Dennis T Ko1,3,4,5
1Division of Cardiology, Schulich Heart Centre and Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, ON, Canada (HCW, DTK).
Insights
For stable coronary artery disease, bare metal stents (BMS) offer a cost-effective initial treatment compared to drug-eluting stents (DES) or optimal medical therapy alone. This analysis considers lifetime costs and quality-adjusted life years.
Area of Science:
- Cardiovascular Medicine
- Health Economics
- Interventional Cardiology
Background:
- Percutaneous coronary intervention (PCI) using drug-eluting stents (DES) or bare metal stents (BMS) improves angina and reduces repeat procedures versus optimal medical therapy.
- However, the increased costs and adverse events associated with stents require further cost-utility evaluation.
Purpose of the Study:
- To conduct a cost-utility analysis comparing initial optimal medical therapy with PCI using BMS or DES for stable coronary artery disease.
- To determine the most cost-effective strategy based on lifetime costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs).
Main Methods:
- A Markov cohort decision model was employed.
- Propensity-matched observational data from Ontario, Canada, provided baseline event rates.
- Effectiveness, utility, and cost data were sourced from published literature and the Ontario Case Costing Initiative.
Main Results:
- Optimal medical therapy had the lowest lifetime costs ($22,952) compared to BMS ($25,081) and DES ($25,536).
- BMS provided a slightly higher QALY (10.26) than DES (10.20), making DES dominated by BMS.
- In diabetic patients with long lesions in small arteries, DES was cost-effective (ICER $18,826/QALY).
Conclusions:
- An initial strategy utilizing bare metal stents (BMS) is cost-effective for patients with stable coronary artery disease.
- The findings suggest that BMS offers a favorable balance of cost and effectiveness in most patient subgroups.
Background:
Percutaneous coronary intervention (PCI) with either drug-eluting stents (DES) or bare metal stents (BMS) reduces angina and repeat procedures compared with optimal medical therapy alone. It remains unclear if these benefits are sufficient to offset their increased costs and small increase in adverse events.
Objective:
Cost utility analysis of initial medical therapy v. PCI with either BMS or DES.
Design:
. Markov cohort decision model. Data Sources. Propensity-matched observational data from Ontario, Canada, for baseline event rates. Effectiveness and utility data obtained from the published literature, with costs from the Ontario Case Costing Initiative.
Target Population:
Patients with stable coronary artery disease, confirmed after angiography, stratified by risk of restenosis based on diabetic status, lesion size, and lesion length. Time Horizon. Lifetime. Perspective. Ontario Ministry of Health and Long Term Care. Interventions. Optimal medical therapy, PCI with BMS or DES.
Outcome Measures:
Lifetime costs, quality-adjusted life years (QALYs), and the incremental cost-effectiveness ratio (ICER).
Results:
of Base Case Analysis. In the overall population, medical therapy had the lowest lifetime costs at $22,952 v. $25,081 and $25,536 for BMS and DES, respectively. Medical therapy had a quality-adjusted life expectancy of 10.1 v. 10.26 QALYs for BMS, producing an ICER of $13,271/QALY. The DES strategy had a quality-adjusted life expectancy of only 10.20 QALYs and was dominated by the BMS strategy. This ranking was consistent in all groups stratified by restenosis risk, except diabetic patients with long lesions in small arteries, in whom DES was cost-effective compared with medical therapy (ICER of $18,826/QALY). Limitations. There is the possibility of residual unobserved confounding.
Conclusions:
In patients with stable coronary artery disease, an initial BMS strategy is cost-effective.
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