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Cost-effectiveness of percutaneous coronary intervention with drug-eluting stents versus bypass surgery for patients
David J Cohen1, Ruben L Osnabrugge2, Elizabeth A Magnuson2
1From Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City (D.J.C., R.L.O., E.A.M., K.W., H.L., K.C.); Erasmus University Medical Center, Rotterdam, The Netherlands (R.L.O., A.P.K., P.W.S.); Harvard School of Public Health, Boston, MA (D.P.); Institut Jacques Cartier, Massy, France (M.-C.M.); Boston Scientific, Natick, MA (K.D.D.); and Herzzentrum Universität Leipzig, Leipzig, Germany (F.W.M.). dcohen@saint-lukes.org.
Background:
The Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery (SYNTAX) trial demonstrated that in patients with 3-vessel or left main coronary artery disease, coronary artery bypass graft surgery (CABG) was associated with a lower rate of cardiovascular death, myocardial infarction, stroke, or repeat revascularization compared with percutaneous coronary revascularization with drug-eluting stents (DES-PCI)). The long-term cost-effectiveness of these strategies is unknown.
Methods And Results:
Between 2005 and 2007, 1800 patients with left main or 3-vessel coronary artery disease were randomized to CABG (n=897) or DES-PCI (n=903). Costs were assessed from a US perspective, and health state utilities were evaluated with the EuroQOL questionnaire. A patient-level microsimulation model based on the 5-year in-trial data was used to extrapolate costs, life expectancy, and quality-adjusted life expectancy over a lifetime horizon. Although initial procedural costs were $3415 per patient lower with CABG, total hospitalization costs were $10 036 per patient higher. Over the next 5 years, follow-up costs were higher with DES-PCI as a result of more frequent hospitalizations, revascularization procedures, and higher medication costs. Over a lifetime horizon, CABG remained more costly than DES-PCI, but the incremental cost-effectiveness ratio was favorable ($16 537 per quality-adjusted life-year gained) and remained <$20 000 per quality-adjusted life-year in most bootstrap replicates. Results were consistent across a wide range of assumptions about the long-term effect of CABG versus DES-PCI on events and costs. In patients with left main disease or a SYNTAX score ≤22, however, DES-PCI was economically dominant compared with CABG, although these findings were less certain.
Conclusions:
For most patients with 3-vessel or left main coronary artery disease, CABG is a clinically and economically attractive revascularization strategy compared with DES-PCI. However, among patients with less complex disease, DES-PCI may be preferred on both clinical and economic grounds.
Clinical Trial Registration Url:
www.clinicaltrials.gov. Unique identifier: NCT00114972.
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