Special article
Cost-effectiveness of bypass surgery versus stenting in patients with multivessel coronary artery disease

https://doi.org/10.1016/S0002-9343(03)00296-1Get rights and content

Abstract

Purpose

To compare the cost-effectiveness of surgical and angioplasty-based coronary artery revascularization techniques, in particular, angioplasty with primary stenting.

Methods

We used data from the Study of Economics and Quality of Life, a substudy of the Bypass Angioplasty Revascularization Investigation (BARI), to measure the outcomes and costs of angioplasty and bypass surgery in patients with multivessel coronary artery disease who had not undergone prior coronary artery revascularization. Using a Markov decision model, we updated the outcomes and costs to reflect technology changes since the time of enrollment in BARI, and projected the lifetime costs and quality-adjusted life-years (QALYs) for the two procedures from the time of initial treatment through death. We accounted for the effects of improved procedural safety and efficiency, and prolonged therapeutic effects of both surgery and stenting. This study was conducted from a societal perspective.

Results

Surgical revascularization was less costly and resulted in better outcomes than catheter-based intervention including stenting. It remained the preferred strategy after adjusting the stent outcomes to eliminate the costs and events associated with target lesion restenosis. Among angioplasty-based strategies, primary stent use cost an additional $189,000 per QALY gained compared with a strategy that reserved stent use for treatment of suboptimal balloon angioplasty results.

Conclusion

Bypass surgery results in better outcomes than angioplasty in patients with multivessel disease, and at a lower cost.

Section snippets

Study design and model

This study is based on data from BARI (22), which involved patients with multivessel disease randomly assigned to either CABG or angioplasty for the treatment of angina. We used decision-analysis software (DATA 4.0; TreeAge, Williamstown, Massachusetts) to model cardiac events from the time of initial revascularization until death. The model estimates the cost to payers for providing revascularization and subsequent medical care, and the quality-adjusted life-years (QALYs) for life with

Model validation

The modeled 4-year costs for balloon angioplasty and CABG corresponded with the costs in SEQOL to within 1.5% 23, 25. The SEQOL time trade-off survey results indicated that over 7.3 years of follow-up, angioplasty patients perceived that 1 year of life equated to 0.848 QALYs, whereas CABG patients experienced slightly better quality of life (0.86 QALYs) (27). The angioplasty model projected an average of 0.84 QALYs per year, compared with 0.86 QALYs per year in the CABG model, which was within

Discussion

Coronary stents were initially approved by the Food and Drug Administration for use in patients with suboptimal angioplasty results. Stent use has reduced both emergency CABG and in-hospital mortality 7, 52, 53, 54. Since 1993, stent use has increased well beyond the provisional indication. In one large study (52), the proportion of provisional stent procedures dropped from 44% to 14% between 1996 and 1998, and primary stent use grew from 44% to 72%.

Because the current study is based on data

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    Supported by Grant 15151 from the Robert Wood Johnson Foundation, Princeton, New Jersey, and by Grant HL-58324 from the National Heart, Lung, and Blood Institute, Bethesda, Maryland.

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