A cost-effectiveness analysis of a hypothetical catheter-based strategy for the detection and treatment of vulnerable coronary plaques with drug-eluting stents.
OBJECTIVE
Extensive efforts are underway to develop methods for the detection and treatment of vulnerable/high-risk coronary artery plaques. We utilized decision analysis to evaluate the hypothetical clinical benefits and cost-effectiveness of a catheter-based strategy.


RESULTS
Currently, stenotic coronary plaques are treated without regard to vulnerability. In a new strategy, vulnerable coronary plaques are detected with a catheter-based test and treated with a drug-eluting stent, regardless of degree of stenosis. A Markov-decision model was developed to compare the new strategy with current practice. Monte Carlo simulations were performed from a societal perspective, costs were converted to year 2003 U.S. dollars, and future costs and outcomes were discounted at 3%. Sensitivity analyses were performed to evaluate the effect of assumptions on variables such as the prevalence of vulnerable plaques and treatment effect. In 60-year-old male patients with coronary stenoses the new strategy would be less expensive and more effective than current practice (37,045 dollars vs 38,257 dollars and 10.23 vs 9.86 quality-adjusted life years (QALYs), respectively). The benefits of the new strategy were robust in sensitivity analyses (e.g., if the prevalence of vulnerable plaques in this patient group was 50% or more and the sensitivity and specificity of the new test were at least 0.80).


CONCLUSIONS
In selected patients with coronary artery stenosis, the detection of vulnerable plaques with a catheter-based test followed by their treatment with a drug-eluting stent could be a less expensive and more effective strategy than current practice. If applied to 1 million such patients in the United States undergoing catheterization, the new strategy would add 370,000 QALYs and save 1.2 billion dollars per year.
Bosch
Johanna L
JL
Institute for Technology Assessment, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA. j.l.bosch@erasmusmc.nl
Beinfeld
Molly T
MT
Muller
James E
JE
Brady
Thomas
T
Gazelle
G Scott
GS
D019917:Blood Vessel Prosthesis Implantation / Q000191:economics; D006328:Cardiac Catheterization / Q000191:economics*; D020099:Coated Materials, Biocompatible / Q000191:economics* / Q000627:therapeutic use*; D023921:Coronary Stenosis / Q000175:diagnosis / Q000191:economics* / Q000628:therapy*; D003362:Cost-Benefit Analysis; D006801:Humans; D008297:Male; D008390:Markov Chains; D008875:Middle Aged; D019057:Quality-Adjusted Life Years; D012680:Sensitivity and Specificity; D015607:Stents / Q000191:economics*; D016896:Treatment Outcome
D020099:Coated Materials, Biocompatible