The Real-World Cost-Effectiveness of Coronary Artery Bypass Surgery Versus Stenting in High-Risk Patients: Propensity Score-Matched Analysis of a Single-Centre Experience
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There are limited economic evaluations comparing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) for multi-vessel coronary artery disease (MVCAD) in contemporary, routine clinical practice.
The aim was to perform a cost-effectiveness analysis comparing CABG and PCI in patients with MVCAD, from the perspective of the Australian public hospital payer, using observational data sources.
Clinical data from the Melbourne Interventional Group (MIG) and the Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) registries were analysed for 1022 CABG (treatment) and 978 PCI (comparator) procedures performed between June 2009 and December 2013. Clinical records were linked to same-hospital admissions and national death index (NDI) data. The incremental cost-effectiveness ratios (ICERs) per major adverse cardiac and cerebrovascular event (MACCE) avoided were evaluated. The propensity score bin bootstrap (PSBB) approach was used to validate base-case results.
At mean follow-up of 2.7 years, CABG compared with PCI was associated with increased costs and greater all-cause mortality, but a significantly lower rate of MACCE. An ICER of $55,255 (Australian dollars)/MACCE avoided was observed for the overall cohort. The ICER varied across comparisons against bare metal stents (ICER $25,815/MACCE avoided), all drug-eluting stents (DES) ($56,861), second-generation DES ($42,925), and third-generation of DES ($88,535). Moderate-to-low ICERs were apparent for high-risk subgroups, including those with chronic kidney disease ($62,299), diabetes ($42,819), history of myocardial infarction ($30,431), left main coronary artery disease ($38,864), and heart failure ($36,966).
At early follow-up, high-risk subgroups had lower ICERs than the overall cohort when CABG was compared with PCI. A personalised, multidisciplinary approach to treatment of patients may enhance cost containment, as well as improving clinical outcomes following revascularisation strategies.
The authors sincerely acknowledge Jason Bryer, Ph.D., Executive Director at Excelsior College, Albany, NY, for writing a program for the propensity score bin bootstrap (PSBB) method in R, for the purpose of this project. The authors sincerely thank Mr. Marco Luthe, former Information Manager—Clinical Costing, at the Alfred Hospital Clinical Performance Unit, for his support with gathering clinical costing data, its interpretation, and performing the record linkage. The following investigators, data managers and institutions participated in the MIG database: The Alfred Hospital: S. J. Duffy, J. A. Shaw, A. Walton, A. Dart, A. Broughton, J. Federman, C. Keighley, C. Hengel, K. H. Peter, D. Stub, W. Chan, S. Nanayakkara, J. O’Brien, L. Selkrig, K. Rankin, R. Huntington, S. Pally; Austin Hospital: D. J. Clark, O. Farouque, M. Horrigan, J. Johns, L. Oliver, J. Brennan, R. Chan, G. Proimos, T. Dortimer, B. Chan, R. Huq, D. Fernando, M. Yudi, K. Charter, L. Brown, A. AlFiadh, J. Ramchand, S. Picardo; Ballarat Base Hospital: E. Oqueli, A. Sharma, C. Hengel, N. Ryan, T. Harrison, C. Barry; Box Hill Hospital: M. Freeman, L. Roberts, A. Teh, M. Rowe, G. Proimos, Y. Cheong, C. Goods, D. Fernando, J. Ramzy, A. Kosky, P. Venkataraman; Monash University: C. Reid, N. Andrianopoulos, A. L. Brennan, D. Dinh, B. P. Yan; Royal Melbourne Hospital: A. E. Ajani, R. Warren, D. Eccleston, J. Lefkovits, R. Iyer, R. Gurvitch, W. Wilson, M. Brooks, S. Biswas, J. Yeoh; University Hospital, Geelong: C. Hiew, M. Sebastian, T. Yip, M. Mok, C. Jaworski, A. Hutchison, M. Turner, B. Khialani, B. McDonald, R. Pavletich. The following investigators, data managers, and institutions participated in the ANZSCTS database: The Alfred Hospital: McGiffin D, Kaczmarek M; Austin Hospital: Matalanis G, Shaw M; Cabrini Health: Rowland M, Shardey G; Epworth HeathCare: Skillington P, Almeida A, Chorley T, Baker L; Geelong Hospital: Seevanayagam S, Bright C; Flinders Medical Centre: Baker R, Edmonds C; Fiona Stanley Hospital: Larbalestier R, Kruger R; Holy Spirit Northside: Fayers T, Kyte, M, Doran C; Jessie McPherson Private Hospital: Smith J, White H; John Hunter Hospital: Seah P, Scaybrook S; Lake Macquarie Hospital: James A, Goodwin K; Liverpool Hospital: French B, Hewitt N; Mater Health Services: Lopez G, Curtis L; Monash Medical Centre: Smith J, White H; Peninsula Private Hospital: Tiruvoipati R, Norton N; Prince of Wales Hospital: Wolfenden H, Muir V; Queensland Health: Milne J; Royal Adelaide Hospital: Worthington M, Wong C; Royal Melbourne Hospital: Tatoulis J, Wynne R; Royal North Shore Hospital: Marshman D, Jovanovic-Palic D; Royal Prince Alfred Hospital: Bannon P, Turner L; Sir Charles Gairdner Hospital: Passage J, Kolybaba M; St George Hospital: Fermanis G, Newbon P; St John of God Hospital: Passage J, Kolybaba M; St Vincent’s Hospital, VIC: Newcomb A, Mack J, Duve K; St Vincent’s Hospital, NSW: Spratt P, Hunter T; The Canberra Hospital: Bissaker P, Dennis N, Burke N; Westmead Hospital: Chard R, Halaka M; Monash CCRE Therapeutics: Tran L, Nag N, Reid CM.
Compliance with Ethical Standards
TVA was supported by the National Heart Foundation of Australia Postgraduate Research Scholarship (PC 10M 5457). SJD’s and CMR’s work is supported by National Health and Medical Research Council of Australia grants. The MIG acknowledges funding from Abbott Vascular, Astra-Zeneca, Medtronic, MSD, Pfizer, Servier, and The Medicines Company. These companies do not have access to data and do not have the right to review manuscripts or abstracts before publication. The Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) National Cardiac Surgery Database Program is funded by the Department of Health and Human Services, Victoria, the Health Administration Corporation (GMCT) and the Clinical Excellence Commission (CEC), NSW, and funding from individual units. ANZSCTS research activities are supported through a National Health and Medical Research Council Senior Research Fellowship and Program Grant awarded to C. M. Reid.
This record linkage study, undertaken as part of this evaluation at The Alfred Hospital, was approved on 24 March 2015 by The Alfred Hospital’s Ethics Committee in the category of a ‘low risk review’ (Project number 142/15).
Conflict of interest
All authors (TVA, ZA, MH, FR, SJD, BP, CHY, JS, BB, BPY, ALB, LT, and CMR) declare no competing interests and take responsibility for all aspects of the data presented (including reliability and freedom from bias) and their discussed interpretation. The authors report no relationships that could be construed as a conflict of interest.
Data availability statement
The datasets generated and analysed during the current study are not publicly available as they contain sensitive patient and hospital-specific information. They may be available in the de-identified form from the corresponding author on reasonable request.
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