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Author Spotlight: Enhancing Coronary Artery Revascularization
Published on: September 15, 2023
Economic Outcomes and Quality of Life After CABG or PCI for Multivessel Disease: The FAME 3 Trial
Mark A Hlatky1, Victoria Y Ding2, Frederik M Zimmermann3
1Division of Cardiovascular Medicine and Stanford Cardiovascular Institute, Stanford University, Stanford, California, USA; Department of Health Policy, Stanford University, Stanford, California, USA.
Insights
Fractional flow reserve-guided PCI offers superior long-term value compared to coronary artery bypass grafting (CABG) for multivessel coronary artery disease (CAD). PCI demonstrates equivalent clinical outcomes at a substantially lower cost, making it a more economically favorable treatment option.
Area of Science:
- Cardiovascular Medicine
- Health Economics
- Interventional Cardiology
Background:
- Previous studies indicated coronary artery bypass grafting (CABG) as cost-effective for multivessel coronary artery disease (CAD).
- Comparative effectiveness and economic outcomes may have evolved with newer treatment strategies.
Purpose of the Study:
- To compare economic and quality of life outcomes between CABG and percutaneous coronary intervention (PCI).
- To determine the cost-effectiveness of CABG versus PCI in the FAME 3 randomized trial.
Main Methods:
- The FAME 3 trial randomized 1,500 patients with 3-vessel CAD to CABG or fractional flow reserve-guided PCI.
- Resource use and quality of life (EuroQOL EQ-5D) were tracked for 5 years.
- Costs were calculated using Medicare rates, and quality-adjusted life-years (QALYs) were derived; cost-effectiveness was assessed via regression and bootstrap analysis.
Main Results:
- CABG incurred 30% higher cumulative costs over 5 years compared to PCI.
- Quality-adjusted life-years (QALYs) were similar between groups, but EQ-5D scores improved faster with PCI.
- PCI showed greater economic value, with lower costs and higher QALYs in 66% of bootstrap replications; CABG's incremental cost-effectiveness ratio exceeded $150,000/QALY in 98% of replications.
Conclusions:
- Fractional flow reserve-guided PCI with zotarolimus drug-eluting stents offers superior long-term value for multivessel CAD.
- PCI provides equivalent clinical outcomes to CABG at a significantly lower cost.
- PCI represents a more economically advantageous treatment strategy for patients with multivessel CAD.
Background:
Previous studies have found coronary artery bypass grafting (CABG) to be cost-effective compared with percutaneous coronary intervention (PCI) among patients with multivessel coronary artery disease (CAD), but their comparative effectiveness and economic outcomes may have changed.
Objectives:
This study sought to compare the economic and quality of life outcomes of CABG vs PCI and determine their cost-effectiveness in the FAME (Fractional Flow Reserve vs Angiography for Multivessel Evaluation) 3 randomized trial.
Methods:
FAME 3 randomly assigned 1,500 patients with 3-vessel CAD to either CABG or fractional flow reserve-guided PCI using zotarolimus drug-eluting stents. We documented resource use and quality of life over 5 years of follow-up. We calculated costs by applying Medicare reimbursement rates to resources used, assessed quality of life using the EuroQOL EQ-5D, calculated quality-adjusted life-years (QALYs) from EQ-5D utility values, and used multivariable regression to compare outcomes by treatment assignment. We calculated the incremental cost-effectiveness ratio based on 5-year outcomes and also on projected life expectancies, and assessed its variability in 10,000 bootstrap replications.
Results:
Cumulative costs over 5 years were 30% higher in patients assigned to CABG (95% CI: 16%-46%; P < 0.001). QALYs over 5 years did not differ significantly between the PCI (4.05 ± 0.84) and CABG groups (4.03 ± 0.82), although EQ-5D scores improved more rapidly after PCI. Patients <65 years of age at enrollment assigned to PCI were more likely to be employed at 5 years (56% vs 47%; P = 0.025). PCI had greater economic value than CABG over 5 years, with lower costs and higher QALYs in 66% of replications, and incremental cost-effectiveness ratios for CABG above the $150,000/QALY benchmark in 98% of bootstrap replications. These findings were essentially unchanged in several lifetime projections based on the outcomes documented within the trial follow-up period.
Conclusions:
Fractional flow reserve-guided PCI using zotarolimus drug-eluting stents provides significantly better long-term value than CABG for treatment of patients with multivessel CAD, with equivalent clinical outcomes at substantially lower cost.
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