title: Cost effectiveness of clinically appropriate decisions on alternative treatments for angina pectoris: prospective observational study.
abstract: OBJECTIVE
  To assess whether revascularisation that is considered to be clinically appropriate is also cost effective.
  
  
  METHODS
  Prospective observational study comparing cost effectiveness of coronary artery bypass grafting, percutaneous coronary intervention, or medical management within groups of patients rated as appropriate for revascularisation.
  
  
  METHODS
  Three tertiary care centres in London.
  
  
  METHODS
  Consecutive, unselected patients rated as clinically appropriate (using a nine member Delphi panel) to receive coronary artery bypass grafting only (n=815); percutaneous coronary intervention only (n=385); or both revascularisation procedures (n=520).
  
  
  METHODS
  Cost per quality adjusted life year gained over six year follow-up, calculated with a National Health Service cost perspective and discounted at 3.5%/year.
  
  
  RESULTS
  Coronary artery bypass grafting cost 22,000 pounds sterling (33,000 euros; $43,000) per quality adjusted life year gained compared with percutaneous coronary intervention among patients appropriate for coronary artery bypass grafting only (59% probability of being cost effective at a cost effectiveness threshold of 30,000 pounds sterling per quality adjusted life year) and 19,000 pounds sterling per quality adjusted life year gained compared with medical management among those appropriate for both types of revascularisation (probability of being cost effective 63%). In none of the three appropriateness groups was percutaneous coronary intervention cost effective at a threshold of 30,000 pounds sterling per quality adjusted life year. Among patients rated appropriate for percutaneous coronary intervention only, the cost per quality adjusted life year gained for percutaneous coronary intervention compared with medical management was 47,000, pounds sterling exceeding usual cost effectiveness thresholds; in these patients, medical management was most likely to be cost effective (probability 54%).
  
  
  CONCLUSIONS
  Among patients judged clinically appropriate for coronary revascularisation, coronary artery bypass grafting seemed cost effective but percutaneous coronary intervention did not. Cost effectiveness analysis based on observational data suggests that the clinical benefit of percutaneous coronary intervention may not be sufficient to justify its cost.
authors.affiliation: Centre for Health Economics, University of York, York, USA.
authors.forename: S C
authors.initials: SC
authors.lastname: Griffin
authors.forename: J A
authors.initials: JA
authors.lastname: Barber
authors.forename: A
authors.initials: A
authors.lastname: Manca
authors.forename: M J
authors.initials: MJ
authors.lastname: Sculpher
authors.forename: S G
authors.initials: SG
authors.lastname: Thompson
authors.forename: M J
authors.initials: MJ
authors.lastname: Buxton
authors.forename: H
authors.initials: H
authors.lastname: Hemingway
mesh_terms: D000787:Angina Pectoris / Q000191:economics* / Q000601:surgery; D015906:Angioplasty, Balloon, Coronary / Q000191:economics; D003362:Cost-Benefit Analysis; D003657:Decision Making; D006801:Humans; D008131:London; D008875:Middle Aged; D009204:Myocardial Revascularization / Q000191:economics*; D011446:Prospective Studies; D016896:Treatment Outcome