title: Cost-effectiveness of percutaneous coronary intervention with drug eluting stents versus bypass surgery for patients with diabetes mellitus and multivessel coronary artery disease: results from the FREEDOM trial.
abstract: BACKGROUND
  Studies from the balloon angioplasty and bare metal stent eras have demonstrated that coronary artery bypass grafting (CABG) is cost-effective compared with percutaneous coronary intervention (PCI) for patients undergoing multivessel coronary revascularization-particularly among patients with complex coronary artery disease or diabetes mellitus. Whether these results apply in the drug-eluting stent (DES) era is unknown.
  
  
  RESULTS
  Between 2005 and 2010, 1900 patients with diabetes mellitus and multivessel coronary artery disease were randomized to PCI with DES (DES-PCI; n=953) or CABG (n=947). Costs were assessed from the perspective of the U.S. health care system. Health state utilities were assessed using the EuroQOL 5 dimension 3 level questionnaire. A patient-level microsimulation model based on U.S. life-tables and in-trial results was used to estimate lifetime cost-effectiveness. Although initial procedural costs were lower for CABG, total costs for the index hospitalization were $8622 higher per patient. Over the next 5 years, follow-up costs were higher with PCI, owing to more frequent repeat revascularization and higher outpatient medication costs. Nonetheless, cumulative 5-year costs remained $3641 higher per patient with CABG. Although there were only modest gains in survival with CABG during the trial period, when the in-trial results were extended to a lifetime horizon, CABG was projected to be economically attractive relative to DES-PCI, with substantial gains in both life expectancy and quality-adjusted life expectancy and incremental cost-effectiveness ratios <$10 000 per life-year or quality-adjusted life-year gained across a broad range of assumptions regarding the effect of CABG on post-trial survival and costs.
  
  
  CONCLUSIONS
  Despite higher initial costs, CABG is a highly cost-effective revascularization strategy compared with DES-PCI for patients with diabetes mellitus and multivessel coronary artery disease.
  
  
  BACKGROUND
  URL: http://www.clinical-trials.gov. Unique identifier: NCT00086450.
authors.affiliation: Saint Luke's Mid America Heart Institute, Kansas City, MO 64111, USA.
authors.forename: Elizabeth A
authors.initials: EA
authors.lastname: Magnuson
authors.forename: Michael E
authors.initials: ME
authors.lastname: Farkouh
authors.forename: Valentin
authors.initials: V
authors.lastname: Fuster
authors.forename: Kaijun
authors.initials: K
authors.lastname: Wang
authors.forename: Katherine
authors.initials: K
authors.lastname: Vilain
authors.forename: Haiyan
authors.initials: H
authors.lastname: Li
authors.forename: Jaime
authors.initials: J
authors.lastname: Appelwick
authors.forename: Victoria
authors.initials: V
authors.lastname: Muratov
authors.forename: Lynn A
authors.initials: LA
authors.lastname: Sleeper
authors.forename: Robin
authors.initials: R
authors.lastname: Boineau
authors.forename: Mouin
authors.initials: M
authors.lastname: Abdallah
authors.forename: David J
authors.initials: DJ
authors.lastname: Cohen
mesh_terms: D000368:Aged; D000553:Ambulatory Care / Q000191:economics / Q000706:statistics & numerical data; D015906:Angioplasty, Balloon, Coronary / Q000191:economics* / Q000401:mortality; D001026:Coronary Artery Bypass / Q000191:economics* / Q000401:mortality; D003324:Coronary Artery Disease / Q000191:economics* / Q000401:mortality / Q000601:surgery / Q000628:therapy; D003362:Cost-Benefit Analysis; D003922:Diabetes Mellitus, Type 1 / Q000191:economics / Q000401:mortality; D003924:Diabetes Mellitus, Type 2 / Q000191:economics / Q000401:mortality; D003925:Diabetic Angiopathies / Q000191:economics* / Q000401:mortality / Q000601:surgery / Q000628:therapy; D054855:Drug-Eluting Stents / Q000191:economics* / Q000706:statistics & numerical data; D005260:Female; D005500:Follow-Up Studies; D017721:Hospital Costs / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D011788:Quality of Life; D019057:Quality-Adjusted Life Years