Cost-effectiveness of coronary stenting and abciximab for patients with acute myocardial infarction: results from the CADILLAC (Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications) trial.
BACKGROUND
Both stenting and the glycoprotein IIb/IIIa inhibitor abciximab improve outcomes for patients undergoing primary angioplasty for acute myocardial infarction (AMI). However, the cost-effectiveness of these strategies is unknown.


RESULTS
We performed a prospective cost-utility analysis among US participants in the CADILLAC trial. Patients with AMI (n=1703) were randomized to stenting versus balloon angioplasty (PTCA) and abciximab versus no abciximab according to a 2-by-2 factorial design. Total 1-year costs and lifetime incremental cost-effectiveness ratios, measured as cost per quality-adjusted year of life (QALY) gained, were calculated. Compared with PTCA, stenting increased procedural costs by 1148 dollars and initial hospital costs by 1384 dollars (both P<0.001). By 1-year, stenting led to fewer repeat revascularization procedures and reduced follow-up medical care costs by 1215 dollars, such that aggregate costs were similar for the PTCA and stent groups (18 690 dollars versus 18 859 dollars, P=0.75). The cost-effectiveness ratio for stenting versus PTCA was favorable at 11 237 dollars/QALY gained and remained <20 000 dollars/QALY in sensitivity analyses. Compared with standard anticoagulation, abciximab increased initial procedural costs by 1122 dollars (P<0.001). By facilitating accelerated hospital discharge, abciximab reduced length of stay by approximately 0.6 days, offsetting most of the drug costs. These cost offsets were not maintained, however; aggregate 1-year costs for the abciximab group were 1244 dollars greater than for standard therapy (19 389 dollars versus 18 145 dollars , P=0.02). Abciximab was reasonably cost-effective (cost-effectiveness ratio 21 305 dollars/QALY) only if nonsignificant differences in 1-year mortality (3.7% versus 4.3%, P=0.62) were incorporated in the analysis.


CONCLUSIONS
Primary stenting is a highly cost-effective treatment for AMI. The cost-effectiveness of abciximab in this setting is uncertain and depends primarily on whether long-term survival is enhanced.
Bakhai
Ameet
A
Harvard Clinical Research Institute, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, Mass 02215, USA.
Stone
Gregg W
GW
Grines
Cindy L
CL
Murphy
Sabina A
SA
Githiora
Louise
L
Berezin
Ronna H
RH
Cox
David A
DA
Stuckey
Thomas
T
Griffin
John J
JJ
Tcheng
James E
JE
Cohen
David J
DJ
D000077284:Abciximab; D000368:Aged; D000800:Angioplasty, Balloon / Q000191:economics; D000911:Antibodies, Monoclonal / Q000191:economics / Q000627:therapeutic use*; D000925:Anticoagulants / Q000191:economics / Q000627:therapeutic use*; D006328:Cardiac Catheterization / Q000191:economics; D023921:Coronary Stenosis / Q000628:therapy; D003362:Cost-Benefit Analysis; D016527:Drug Costs; D005260:Female; D005500:Follow-Up Studies; D017048:Health Care Costs / Q000706:statistics & numerical data*; D017721:Hospital Costs; D006801:Humans; D007140:Immunoglobulin Fab Fragments / Q000191:economics / Q000627:therapeutic use*; D007902:Length of Stay / Q000191:economics / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000188:drug therapy / Q000401:mortality / Q000601:surgery / Q000628:therapy*; D009204:Myocardial Revascularization / Q000191:economics / Q000706:statistics & numerical data; D011446:Prospective Studies; D012008:Recurrence; D015607:Stents / Q000191:economics; D016019:Survival Analysis
D000911:Antibodies, Monoclonal; D000925:Anticoagulants; D007140:Immunoglobulin Fab Fragments; D000077284:Abciximab