title: Cost-effectiveness of percutaneous coronary intervention versus bypass surgery from a Dutch perspective.
abstract: OBJECTIVE
  Recent cost-effectiveness analyses of percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) have been limited by a short time horizon or were restricted to the US healthcare perspective. We, therefore, used individual patient-level data from the SYNTAX trial to evaluate the cost-effectiveness of PCI versus CABG from a European (Dutch) perspective.
  
  
  RESULTS
  Between 2005 and 2007, 1800 patients with three-vessel or left main coronary artery disease were randomised to either CABG (n=897) or PCI with drug-eluting stents (DES; n=903). Costs were estimated for all patients based on observed healthcare resource usage over 5 years of follow-up. Health state utilities were evaluated with the EuroQOL questionnaire. A patient-level microsimulation model based on Dutch life-tables was used to extrapolate the 5-year in-trial data to a lifetime horizon. Although initial procedural costs were lower for CABG, total initial hospitalisation costs per patient were higher (€17 506 vs €14 037, p<0.001). PCI was more costly during the next 5 years of follow-up, due to more frequent hospitalisations, repeat revascularisation procedures and higher medication costs. Nevertheless, total 5-year costs remained €2465/patient higher with CABG. When the in-trial results were extrapolated to a lifetime horizon, CABG was projected to be economically attractive relative to DES-PCI, with gains in both life expectancy and quality-adjusted life expectancy. The incremental cost-effectiveness ratio (ICER) (€5390/quality-adjusted life year (QALY) gained) was favourable and remained <€80 000/QALY in >90% of the bootstrap replicates. Outcomes were similar when incorporating the prognostic impact of non-fatal myocardial infarction and stroke, as well as across a broad range of assumptions regarding the effect of CABG on post-trial survival and costs. However, DES-PCI was economically dominant compared with CABG in patients with a SYNTAX Score ≤22 or in those with left main disease. In patients for whom the SYNTAX Score II favoured PCI based on lower predicted 4-year mortality, PCI was also economically dominant, whereas in those patients for whom the SYNTAX Score II favoured surgery, CABG was highly economically attractive (ICER range, €2967 to €3737/QALY gained).
  
  
  CONCLUSIONS
  For the broad population with three-vessel or left main disease who are candidates for either CABG or PCI, we found that CABG is a clinically and economically attractive revascularisation strategy compared with DES-PCI from a Dutch healthcare perspective. The cost-effectiveness of CABG versus PCI differed according to several anatomic factors, however. The newly developed SYNTAX Score II provides enhanced prognostic discrimination in this population, and may be a useful tool to guide resource allocation as well.
  
  
  BACKGROUND
  Clinical trial unique identifier: NCT00114972 (http://www.clinical-trials.gov).
authors.affiliation: Department of Cardiovascular Research, Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri, USA Department of Cardio-Thoracic Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands.
authors.forename: Ruben L
authors.initials: RL
authors.lastname: Osnabrugge
authors.affiliation: Department of Cardiovascular Research, Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri, USA.
authors.forename: Elizabeth A
authors.initials: EA
authors.lastname: Magnuson
authors.affiliation: Department of Cardiology, Erasmus University Medical Centre, Rotterdam, The Netherlands.
authors.forename: Patrick W
authors.initials: PW
authors.lastname: Serruys
authors.affiliation: Department of Cardiology, Erasmus University Medical Centre, Rotterdam, The Netherlands Heart Institute (InCor), University of São Paulo Medical School, Sao Paulo, Brazil.
authors.forename: Carlos M
authors.initials: CM
authors.lastname: Campos
authors.affiliation: Department of Cardiovascular Research, Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri, USA.
authors.forename: Kaijun
authors.initials: K
authors.lastname: Wang
authors.affiliation: Department of Public Health, Erasmus University Medical Centre, Rotterdam, The Netherlands.
authors.forename: David
authors.initials: D
authors.lastname: van Klaveren
authors.affiliation: Department of Cardiology, Erasmus University Medical Centre, Rotterdam, The Netherlands.
authors.forename: Vasim
authors.initials: V
authors.lastname: Farooq
authors.affiliation: Department of Cardiovascular Research, Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri, USA.
authors.forename: Mouin S
authors.initials: MS
authors.lastname: Abdallah
authors.affiliation: Department of Cardiovascular Research, Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri, USA.
authors.forename: Haiyan
authors.initials: H
authors.lastname: Li
authors.affiliation: Department of Cardiovascular Research, Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri, USA.
authors.forename: Katherine A
authors.initials: KA
authors.lastname: Vilain
authors.affiliation: Department of Public Health, Erasmus University Medical Centre, Rotterdam, The Netherlands.
authors.forename: Ewout W
authors.initials: EW
authors.lastname: Steyerberg
authors.affiliation: Department of Interventional Cardiology, Institut Jacques Cartier, Massy, France.
authors.forename: Marie-Claude
authors.initials: MC
authors.lastname: Morice
authors.affiliation: Boston Scientific Corporation, Natick, Massachusetts, USA.
authors.forename: Keith D
authors.initials: KD
authors.lastname: Dawkins
authors.affiliation: Department of Cardiac Surgery, Herzzentrum Universität Leipzig, Leipzig, Germany.
authors.forename: Friedrich W
authors.initials: FW
authors.lastname: Mohr
authors.affiliation: Department of Cardio-Thoracic Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands.
authors.forename: A Pieter
authors.initials: AP
authors.lastname: Kappetein
authors.affiliation: Department of Cardiovascular Research, Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri, USA.
authors.forename: David J
authors.initials: DJ
authors.lastname: Cohen
mesh_terms: D003198:Computer Simulation; D001026:Coronary Artery Bypass / Q000009:adverse effects / Q000191:economics* / Q000401:mortality; D003324:Coronary Artery Disease / Q000175:diagnosis / Q000191:economics* / Q000401:mortality / Q000628:therapy*; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D054855:Drug-Eluting Stents / Q000191:economics; D006304:Health Status; D017721:Hospital Costs; D006801:Humans; D007902:Length of Stay / Q000191:economics; D018803:Models, Economic; D009426:Netherlands; D010359:Patient Readmission / Q000191:economics; D018579:Patient Selection; D062645:Percutaneous Coronary Intervention / Q000009:adverse effects / Q000191:economics* / Q000295:instrumentation / Q000401:mortality; D011788:Quality of Life; D019057:Quality-Adjusted Life Years; D019233:Retreatment / Q000191:economics; D011795:Surveys and Questionnaires; D013997:Time Factors; D016896:Treatment Outcome