Cost-effectiveness of gamma radiation for treatment of in-stent restenosis: results from the Gamma-1 trial.
BACKGROUND
Recently, several randomized trials have demonstrated that intracoronary brachytherapy can reduce the rates of both angiographic and clinical restenosis in patients undergoing percutaneous coronary intervention (PCI) for in-stent restenosis. Whether this practice is cost-effective is unknown.


RESULTS
Between December 1997 and July 1998, 252 patients with in-stent restenosis were randomized to receive brachytherapy or placebo after successful PCI as part of the Gamma-1 trial. We collected detailed resource utilization and cost data for each patient's initial hospitalization and for 1 year after randomization. Compared with conventional treatment, intracoronary brachytherapy increased procedure duration, physician services, and equipment costs. As a result, initial costs were increased by nearly $4100 per patient ($15 724 versus $11 675, P<0.001). Over the 1-year follow-up period, brachytherapy reduced the need for repeat revascularization by 21% and reduced the need for bypass surgery by 44%. Although follow-up medical care costs were $2200/patient lower with brachytherapy, total costs remained higher at 1 year ($28 543 versus $26 737, P=0.46). In a sensitivity analysis that incorporated recent technical modifications and the use of prolonged antiplatelet therapy to prevent late thrombotic occlusion, follow-up cost savings increased to $3600/patient, and 1-year costs were slightly lower with brachytherapy ($26 352 versus $26 729, P=0.87). Subgroup analysis demonstrated significant cost savings in patients with diabetes and patients who did not undergo repeat stenting.


CONCLUSIONS
As performed in the Gamma-1 trial, coronary brachytherapy for in-stent restenosis improved clinical outcomes but increased 1-year costs compared with standard therapy. If late thrombosis can be eliminated, however, this technology has the potential to reduce overall medical care costs.
Cohen
David J
DJ
Cardiovascular Division, Beth Israel Deaconess Medical Center, Boston, Mass 02215, USA. dcohen@caregroup.harvard.edu
Cosgrove
Roberta S
RS
Berezin
Ronna H
RH
Teirstein
Paul S
PS
Leon
Martin B
MB
Kuntz
Richard E
RE
D015906:Angioplasty, Balloon, Coronary; D001918:Brachytherapy / Q000191:economics*; D023903:Coronary Restenosis / Q000191:economics* / Q000209:etiology / Q000532:radiotherapy*; D003328:Coronary Thrombosis / Q000191:economics / Q000209:etiology; D017281:Cost of Illness; D003362:Cost-Benefit Analysis; D004311:Double-Blind Method; D005260:Female; D005720:Gamma Rays / Q000627:therapeutic use*; D006801:Humans; D008297:Male; D008875:Middle Aged; D015607:Stents / Q000009:adverse effects*