Cost-effectiveness of percutaneous coronary intervention in optimally treated stable coronary patients.
BACKGROUND
The COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive druG Evaluations) trial compared the effect of percutaneous coronary intervention (PCI) plus optimal medical therapy with optimal medical therapy alone on cardiovascular events in 2287 patients with stable coronary disease. After 4.6 years, there was no difference in the primary end point of death or myocardial infarction, although PCI improved quality of life. The present study evaluated the relative cost and cost-effectiveness of PCI in the COURAGE trial.


RESULTS
Resource use was assessed by diagnosis-related group for hospitalizations and by current procedural terminology code for outpatient visits and tests and then converted to costs by use of 2004 Medicare payments. Medication costs were assessed with the Red Book average wholesale price. Life expectancy beyond the trial was estimated from Framingham survival data. Utilities were assessed by the standard gamble method. The incremental cost-effectiveness ratio was expressed as cost per life-year and cost per quality-adjusted life-year gained. The added cost of PCI was approximately $10,000, without significant gain in life-years or quality-adjusted life-years. The incremental cost-effectiveness ratio varied from just over $168,000 to just under $300,000 per life-year or quality-adjusted life-year gained with PCI. A large minority of the distributions found that medical therapy alone offered better outcome at lower cost. The costs per patient for a significant improvement in angina frequency, physical limitation, and quality of life were $154,580, $112,876, and $124,233, respectively.


CONCLUSIONS
The COURAGE trial did not find the addition of PCI to optimal medical therapy to be a cost-effective initial management strategy for symptomatic, chronic coronary artery disease.
Weintraub
William S
WS
Christiana Care Health System, Newark, DE 19718, USA. wweintraub@christianacare.org
Boden
William E
WE
Zhang
Zugui
Z
Kolm
Paul
P
Zhang
Zefeng
Z
Spertus
John A
JA
Hartigan
Pamela
P
Veledar
Emir
E
Jurkovitz
Claudine
C
Bowen
Jim
J
Maron
David J
DJ
O'Rourke
Robert
R
Dada
Marcin
M
Teo
Koon K
KK
Goeree
Ron
R
Barnett
Paul G
PG
D000368:Aged; D015906:Angioplasty, Balloon, Coronary / Q000191:economics* / Q000639:trends; D003324:Coronary Artery Disease / Q000191:economics* / Q000453:epidemiology / Q000503:physiopathology / Q000628:therapy*; D003362:Cost-Benefit Analysis; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D011788:Quality of Life