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Published on: November 19, 2019
Cost-effectiveness of bilateral vs. single internal thoracic artery grafts at 10 years
Matthew Little1, Alastair M Gray1, Douglas G Altman2
1Nuffield Department of Population Health, Health Economics Research Centre, University of Oxford, Old Road Campus, Headington, Oxford OX3 7LF, UK.
Insights
Bilateral internal thoracic arteries (BITA) grafting is more expensive than single internal thoracic arteries (SITA) grafting, with similar survival benefits at 10 years. Long-term projections suggest BITA may become more cost-effective over a patient's lifetime.
Area of Science:
- Cardiovascular Surgery
- Health Economics
- Clinical Trial Analysis
Background:
- Coronary artery bypass grafting (CABG) is a critical intervention for advanced coronary artery disease.
- Bilateral internal thoracic arteries (BITA) grafting is hypothesized to offer superior survival outcomes compared to single internal thoracic artery (SITA) grafting.
- Assessing the long-term cost-effectiveness of BITA versus SITA grafting is crucial for healthcare resource allocation.
Purpose of the Study:
- To evaluate the long-term cost-effectiveness of BITA grafting compared to SITA grafting in patients with advanced coronary artery disease.
- To analyze resource utilization, healthcare expenditures, and quality-adjusted life years (QALYs) over a 10-year follow-up period.
- To extrapolate findings to a lifetime perspective to inform clinical and economic decision-making.
Main Methods:
- Utilized data from the Arterial Revascularization Trial (ART) from an English healthcare system perspective.
- Employed intention-to-treat analysis with multiple imputation for missing data.
- Calculated incremental cost-effectiveness ratios (ICERs) with uncertainty analysis via bootstrapping and extrapolated long-term outcomes using statistical models.
Main Results:
- BITA grafting incurred higher mean costs (£17,594) compared to SITA grafting (£16,462) at 10 years (mean difference £1133, P=0.015).
- Quality-adjusted survival was comparable between BITA (6.54 QALYs) and SITA (6.57 QALYs) at 10 years (P=0.883).
- At 10 years, BITA had a 33% probability of cost-effectiveness versus SITA at a £20,000 threshold; lifetime extrapolation increased this to 51%.
Conclusions:
- BITA grafting demonstrates significantly higher upfront costs but yields similar quality-adjusted survival to SITA grafting at the 10-year mark.
- The economic advantage of BITA grafting may emerge over the long term, as suggested by lifetime extrapolation models.
- These findings necessitate careful consideration of long-term value in decisions regarding arterial graft selection for CABG.
Aims:
Using bilateral internal thoracic arteries (BITAs) for coronary artery bypass grafting (CABG) has been suggested to improve survival compared to CABG using single internal thoracic arteries (SITAs) for patients with advanced coronary artery disease. We used data from the Arterial Revascularization Trial (ART) to assess long-term cost-effectiveness of BITA grafting compared to SITA grafting from an English health system perspective.
Methods And Results:
Resource use, healthcare costs, and quality-adjusted life years (QALYs) were assessed across 10 years of follow-up from an intention-to-treat perspective. Missing data were addressed using multiple imputation. Incremental cost-effectiveness ratios were calculated with uncertainty characterized using non-parametric bootstrapping. Results were extrapolated beyond 10 years using Gompertz functions for survival and linear models for total cost and utility. Total mean costs at 10 years of follow-up were £17 594 in the BITA arm and £16 462 in the SITA arm [mean difference £1133 95% confidence interval (CI) £239 to £2026, P = 0.015]. Total mean QALYs at 10 years were 6.54 in the BITA arm and 6.57 in the SITA arm (adjusted mean difference -0.01 95% CI -0.2 to 0.1, P = 0.883). At 10 years, BITA grafting had a 33% probability of being cost-effective compared to SITA, assuming a cost-effectiveness threshold of £20 000. Lifetime extrapolation increased the probability of BITA being cost-effective to 51%.
Conclusions:
BITA grafting has significantly higher costs but similar quality-adjusted survival at 10 years compared to SITA grafting. Extrapolation suggests this could change over lifetime.
