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Published on: March 27, 2018
The Real-World Cost-Effectiveness of Coronary Artery Bypass Surgery Versus Stenting in High-Risk Patients: Propensity
Thathya V Ariyaratne1, Zanfina Ademi2,3, Molla Huq4
1Department of Epidemiology and Preventive Medicine (DEPM), Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, 6th Floor, 99 Commercial Rd, Melbourne, VIC, 3004, Australia. chris.reid@monash.edu.
Insights
Coronary artery bypass grafting (CABG) is more costly but reduces major adverse cardiac and cerebrovascular events (MACCE) compared to percutaneous coronary intervention (PCI) in multi-vessel coronary artery disease. High-risk patients show better cost-effectiveness for CABG.
Area of Science:
- Cardiovascular Medicine
- Health Economics
- Interventional Cardiology
Background:
- Limited economic evaluations exist for coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI) in multi-vessel coronary artery disease (MVCAD).
- Contemporary clinical practice data is needed to assess the cost-effectiveness of these revascularization strategies.
Purpose of the Study:
- To conduct a cost-effectiveness analysis comparing CABG and PCI for patients with MVCAD.
- To evaluate outcomes from the perspective of the Australian public hospital payer.
Main Methods:
- Analysis of clinical data from the Melbourne Interventional Group (MIG) and ANZSCTS registries (2009-2013).
- Inclusion of 1022 CABG and 978 PCI procedures, linked to hospital admissions and national death index data.
- Calculation of incremental cost-effectiveness ratios (ICERs) per major adverse cardiac and cerebrovascular event (MACCE) avoided, using propensity score bin bootstrap validation.
Main Results:
- CABG incurred higher costs and mortality but significantly reduced MACCE compared to PCI at 2.7 years follow-up.
- Overall cohort ICER was $55,255 AUD per MACCE avoided.
- ICERs varied by stent type (e.g., $25,815 for bare metal stents, $88,535 for third-generation DES) and patient subgroups (e.g., $30,431 for myocardial infarction history, $36,966 for heart failure).
Conclusions:
- High-risk patient subgroups demonstrated lower ICERs for CABG compared to PCI.
- Personalized, multidisciplinary approaches may improve cost containment and clinical outcomes in revascularization strategies.
Background:
There are limited economic evaluations comparing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) for multi-vessel coronary artery disease (MVCAD) in contemporary, routine clinical practice.
Objective:
The aim was to perform a cost-effectiveness analysis comparing CABG and PCI in patients with MVCAD, from the perspective of the Australian public hospital payer, using observational data sources.
Methods:
Clinical data from the Melbourne Interventional Group (MIG) and the Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) registries were analysed for 1022 CABG (treatment) and 978 PCI (comparator) procedures performed between June 2009 and December 2013. Clinical records were linked to same-hospital admissions and national death index (NDI) data. The incremental cost-effectiveness ratios (ICERs) per major adverse cardiac and cerebrovascular event (MACCE) avoided were evaluated. The propensity score bin bootstrap (PSBB) approach was used to validate base-case results.
Results:
At mean follow-up of 2.7 years, CABG compared with PCI was associated with increased costs and greater all-cause mortality, but a significantly lower rate of MACCE. An ICER of $55,255 (Australian dollars)/MACCE avoided was observed for the overall cohort. The ICER varied across comparisons against bare metal stents (ICER $25,815/MACCE avoided), all drug-eluting stents (DES) ($56,861), second-generation DES ($42,925), and third-generation of DES ($88,535). Moderate-to-low ICERs were apparent for high-risk subgroups, including those with chronic kidney disease ($62,299), diabetes ($42,819), history of myocardial infarction ($30,431), left main coronary artery disease ($38,864), and heart failure ($36,966).
Conclusions:
At early follow-up, high-risk subgroups had lower ICERs than the overall cohort when CABG was compared with PCI. A personalised, multidisciplinary approach to treatment of patients may enhance cost containment, as well as improving clinical outcomes following revascularisation strategies.
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