Cost-effectiveness of coronary artery bypass grafts versus percutaneous coronary intervention for revascularization of high-risk patients.
BACKGROUND
A Department of Veterans Affairs Cooperative Study randomized high-risk patients with medically refractory myocardial ischemia, a group largely excluded from previous trials, to urgent revascularization with either percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). The present study examined the cost-effectiveness of PCI versus CABG for these high-risk patients.


RESULTS
Of 454 patients at 16 Department of Veterans Affairs medical centers, 445 were available for the economic analysis (218 PCI and 227 CABG patients). Total costs were assessed at 3 and 5 years from the third-party payer's perspective, and effectiveness was measured by survival. After 3 years, average total costs were 63,896 dollars for PCI versus 84,364 dollars for CABG patients, a difference of 20,468 dollars (95% confidence interval [CI] 13,918 dollars to 27,569 dollars). CIs were estimated by bootstrapping. Survival at 3 years was 0.82 for PCI versus 0.79 for CABG patients (P=0.34). Precision of the cost-effectiveness estimates were assessed by bootstrapping. PCI was less costly and more effective at 3 years in 92.6% of the bootstrap replications. After 5 years, average total costs were 81,790 dollars for PCI versus 100,522 dollars for CABG patients, a difference of 18,732 dollars (95% CI 9873 dollars to 27,831 dollars), whereas survival at 5 years was 0.75 for PCI patients versus 0.70 for CABG patients (P=0.21). At 5 years, PCI remained less costly and more effective in 89.4% of the bootstrap replications.


CONCLUSIONS
PCI was less costly and at least as effective for the urgent revascularization of medically refractory, high-risk patients over 5 years.
Stroupe
Kevin T
KT
Cooperative Studies Program Coordinating Center, Hines VA Hospital, PO Box 5000 (151H), Hines, IL 60141, USA. Kevin.Stroupe@va.gov
Morrison
Douglass A
DA
Hlatky
Mark A
MA
Barnett
Paul G
PG
Cao
Lishan
L
Lyttle
Christopher
C
Hynes
Denise M
DM
Henderson
William G
WG
D000368:Aged; D015906:Angioplasty, Balloon, Coronary / Q000009:adverse effects / Q000191:economics*; D001026:Coronary Artery Bypass / Q000009:adverse effects / Q000191:economics*; D003324:Coronary Artery Disease / Q000191:economics* / Q000503:physiopathology / Q000628:therapy*; D003362:Cost-Benefit Analysis; D005260:Female; D017048:Health Care Costs; D006801:Humans; D008297:Male; D008875:Middle Aged; D017202:Myocardial Ischemia / Q000191:economics / Q000503:physiopathology / Q000628:therapy*; D009204:Myocardial Revascularization / Q000009:adverse effects / Q000191:economics / Q000379:methods* / Q000706:statistics & numerical data; D011787:Quality of Health Care; D012307:Risk Factors; D016019:Survival Analysis; D016896:Treatment Outcome