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Applied Health Economics and Health Policy

, Volume 16, Issue 5, pp 661–674 | Cite as

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

  • Thathya V. Ariyaratne
  • Zanfina Ademi
  • Molla Huq
  • Franklin Rosenfeldt
  • Stephen J. Duffy
  • Bonny Parkinson
  • Cheng-Hon Yap
  • Julian Smith
  • Baki Billah
  • Bryan P. Yan
  • Angela L. Brennan
  • Lavinia Tran
  • Christopher M. Reid
Original Research Article

Abstract

Background

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.

Objective

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.

Methods

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.

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).

Conclusions

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.

Notes

Acknowledgements

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

Funding

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.

Ethics committee

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.

Supplementary material

40258_2018_407_MOESM1_ESM.docx (107 kb)
Supplementary material 1 (DOCX 106 kb)
40258_2018_407_MOESM2_ESM.docx (288 kb)
Supplementary material 2 (DOCX 288 kb)

References

  1. 1.
    Epstein AJ, Polsky D, Yang F, Yang L, Groeneveld PW. Coronary revascularization trends in the United States, 2001–2008. JAMA. 2011;305:1769–76.CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Movahed MR, Ramaraj R, Khoynezhad A, Hashemzadeh M, Hashemzadeh M. Declining in-hospital mortality in patients undergoing coronary bypass surgery in the United states irrespective of presence of type 2 diabetes or congestive heart failure. Clin Cardiol. 2012;35:297–300.CrossRefPubMedGoogle Scholar
  3. 3.
    Stettler C, Wandel S, Allemann S, et al. Outcomes associated with drug-eluting and bare-metal stents: a collaborative network meta-analysis. Lancet. 2007;370:937–48.CrossRefPubMedGoogle Scholar
  4. 4.
    Kirtane AJ, Gupta A, Iyengar S, et al. Safety and efficacy of drug-eluting and bare metal stents. Compr Meta Anal Random Trials Obs Stud. 2009;119:3198–206.Google Scholar
  5. 5.
    Yan BP, Clark DJ, Buxton B, et al. Clinical characteristics and early mortality of patients undergoing coronary artery bypass grafting compared to percutaneous coronary intervention: Insights from the Australasian Society of Cardiac and Thoracic Surgeons (ASCTS) and the Melbourne Interventional Group (MIG) Registries. Heart Lung Circ. 2009;18:184–90.CrossRefPubMedGoogle Scholar
  6. 6.
    Farkouh ME, Domanski M, Sleeper LA, et al. Strategies for multivessel revascularization in patients with diabetes. N Engl J Med. 2012;367:2375–84.CrossRefPubMedGoogle Scholar
  7. 7.
    Kamalesh M, Sharp TG, Tang XC, et al. Percutaneous coronary intervention versus coronary bypass surgery in United States veterans with diabetes. J Am Coll Cardiol. 2013;61:808–16.CrossRefPubMedGoogle Scholar
  8. 8.
    Kapur A, Hall RJ, Malik IS, et al. Randomized comparison of percutaneous coronary intervention with coronary artery bypass grafting in diabetic patients: 1-year results of the CARDia (Coronary Artery Revascularization in Diabetes) trial. J Am Coll Cardiol. 2010;55:432–40.CrossRefPubMedGoogle Scholar
  9. 9.
    Mack MJ, Banning AP, Serruys PW, et al. Bypass versus drug-eluting stents at three years in SYNTAX patients with diabetes mellitus or metabolic syndrome. Ann Thorac Surg. 2011;92:2140–6.CrossRefPubMedGoogle Scholar
  10. 10.
    Cohen DJ, Osnabrugge RL, Magnuson EA, et al. Cost-effectiveness of percutaneous coronary intervention with drug-eluting stents vs. bypass surgery for patients with 3-vessel or left main coronary artery disease: final results from the SYNTAX trial. Circulation. 2014;130:1146–57.CrossRefPubMedGoogle Scholar
  11. 11.
    Magnuson EA, Farkouh ME, Fuster V, et al. Cost-effectiveness of percutaneous coronary intervention with drug eluting stents versus bypass surgery for patients with diabetes and multivessel coronary artery disease: results from the FREEDOM trial. Circulation. 2012;127:820–31.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Ariyaratne TV, Ademi Z, Yap C-H, et al. Prolonged effectiveness of coronary artery bypass surgery versus drug-eluting stents in diabetics with multi-vessel disease: an updated systematic review and meta-analysis. Int J Cardiol. 2014;176:346–53.CrossRefPubMedGoogle Scholar
  13. 13.
    Silverman SL. From randomized controlled trials to observational studies. Am J Med. 2009;122:114–20.CrossRefPubMedGoogle Scholar
  14. 14.
    Saxena A, Newcomb AE, Dhurandhar V, Bannon PG. Application of clinical databases to contemporary cardiac surgery practice: where are we now? Heart Lung Circ. 2016;25:237–42.CrossRefPubMedGoogle Scholar
  15. 15.
    Glick HA, Doshi JA, Sonnad SS, Polsky D. Economic evaluation in clinical trials. Oxford: OUP; 2014.CrossRefGoogle Scholar
  16. 16.
    Meenan RT, Goodman MJ, Fishman PA, Hornbrook MC, O Keeffe-Rosetti MC, Bachman DJ. Issues in pooling administrative data for economic evaluation. Am J Manag Care. 2002;8:45–56.PubMedGoogle Scholar
  17. 17.
    Zhao X, Zhou Y, Song H, et al. Comparison of bypass surgery with drug-eluting stents in diabetic patients with left main coronary stenosis. Yonsei Med J. 2011;52:923–32.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    K-i Yamagata, Kataoka Y, Kokubu N, et al. A 3-year clinical outcome after percutaneous coronary intervention using sirolimus-eluting stent and off-pump coronary artery bypass grafting for the treatment of diabetic patients with multivessel disease. Circ J. 2010;74:671–8.CrossRefGoogle Scholar
  19. 19.
    Qiao Y, Ma C, Nie S, et al. Twelve months clinical outcome of drug-eluting stents implantation or coronary artery bypass surgery for the treatment of diabetic patients with multivessel disease. Clin Cardiol. 2009;32:E24–30.CrossRefPubMedGoogle Scholar
  20. 20.
    Kim Y-G, Park D-W, Lee WS, et al. Influence of diabetes mellitus on long-term (five-year) outcomes of drug-eluting stents and coronary artery bypass grafting for multivessel coronary revascularization. Am J Cardiol. 2012;109:1548–57.CrossRefPubMedGoogle Scholar
  21. 21.
    Domínguez-Franco AJ, Jiménez-Navarro MF, Hernández-García JM, et al. Comparison of medium-term outcomes obtained with drug-eluting stents and coronary artery bypass grafts in an unselected population of diabetic patients with multivessel coronary disease. Propensity score analysis. Revista Española de Cardiología (English Edition). 2009;62:491–500.CrossRefGoogle Scholar
  22. 22.
    Zhang Z, Kolm P, Grau-Sepulveda MV, et al. Cost-effectiveness of revascularization strategies: the ASCERT study. J Am Coll Cardiol. 2015;65:1–11.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Osnabrugge RL, Speir AM, Head SJ, et al. Prediction of costs and length of stay in coronary artery bypass grafting. Ann Thorac Surg. 2014;98:1286–93.CrossRefPubMedGoogle Scholar
  24. 24.
    Jacobs JP, Edwards FH, Shahian DM, et al. Successful linking of the Society of Thoracic Surgeons adult cardiac surgery database to Centers for Medicare and Medicaid Services Medicare data. Ann Thorac Surg. 2010;90:1150–7.CrossRefPubMedGoogle Scholar
  25. 25.
    Brennan JM, Peterson ED, Messenger JC, et al. Linking the national cardiovascular data registry CathPCI Registry with Medicare claims data. Circ Cardiovasc Qual Outcomes. 2012;5:134–40.CrossRefPubMedGoogle Scholar
  26. 26.
    Klein LW, Edwards FH, DeLong ER, Ritzenthaler L, Dangas GD, Weintraub WS. ASCERT: the American College of Cardiology Foundation—the Society of Thoracic Surgeons Collaboration on the comparative effectiveness of revascularization strategies. JACC Cardiovasc Interv. 2010;3:124–6.CrossRefPubMedGoogle Scholar
  27. 27.
    Ariyaratne TV, Yap C-H, Ademi Z, et al. A systematic review of cost-effectiveness of percutaneous coronary intervention vs. surgery for the treatment of multivessel coronary artery disease in the drug-eluting stent era. Eur Heart J Qual Care Clin Outcomes. 2016;2:261–70.CrossRefPubMedGoogle Scholar
  28. 28.
    Chan W, Clark DJ, Ajani AE, et al. Progress towards a national cardiac procedure database—development of the Australasian Society of Cardiac and Thoracic Surgeons (ASCTS) and Melbourne Interventional Group (MIG) registries. Heart Lung Circ. 2011;20:10–8.CrossRefPubMedGoogle Scholar
  29. 29.
    Stuart EA. Matching methods for causal inference: a review and a look forward. Stat Sci Rev J Inst Math Stat. 2010;25:1.Google Scholar
  30. 30.
    Caliendo M, Kopeinig S. Some practical guidance for the implementation of propensity score matching. J Econ Surv. 2008;22:31–72.CrossRefGoogle Scholar
  31. 31.
    Faries DE, Peng X, Obenchain RL. Costs and cost effectiveness analysis using propensity score bin bootstrapping. In: Faries DE, Leon AC, Haro JM, Obenchain RL, editors. Analysis of Observational Health Care Data Using SAS. Cary, NC: SAS Institute; 2010.Google Scholar
  32. 32.
    Lin D, Feuer E, Etzioni R, Wax Y. Estimating medical costs from incomplete follow-up data. Biometrics. 1997;53:419–34.CrossRefPubMedGoogle Scholar
  33. 33.
    Australian Government Medical Services Advisory Committee 2017. MSAC Applications Page. http://www.msac.gov.au/internet/msac/publishing.nsf/Content/application-page. Accessed 23 Mar 2017.
  34. 34.
    Australian Institute of Health and Welfare 2016. Health expenditure Australia 2014–15. Health and welfare expenditure series no. 57. Cat. no. HWE 67. Canberra: AIHW.Google Scholar
  35. 35.
    Medicare Benefits Scedule (MBS) Online. http://www.mbsonline.gov.au/internet/mbsonline/publishing.nsf/Content/Home. Accessed 4 Jan 2017.
  36. 36.
    Wang X, Rokoss M, Dyub A, Gafni A, Lamy A. Cost comparison of four revascularisation procedures for the treatment of multivessel coronary artery disease. J Med Econ. 2008;11:119–34.CrossRefPubMedGoogle Scholar
  37. 37.
    Perikhanyan A. Effectiveness and cost-effectiveness of coronary artery bypass surgery versus drug eluting stents in Armenia: a feasibility study. Georgian Med News. 2011;6:44–51.Google Scholar
  38. 38.
    Legrand VM, Serruys PW, Unger F, et al. Three-year outcome after coronary stenting versus bypass surgery for the treatment of multivessel disease. Circulation. 2004;109:1114–20.CrossRefPubMedGoogle Scholar
  39. 39.
    De Feyter P, Serruys P, Unger F, et al. Bypass surgery versus stenting for the treatment of multivessel disease in patients with unstable angina compared with stable angina. Circulation. 2002;105:2367–72.CrossRefPubMedGoogle Scholar
  40. 40.
    Fryback DG, Dasbach EJ, Klein R, et al. The Beaver Dam Health Outcomes Study: initial catalog of health-state quality factors. Med Decis Mak. 1993;13:89–102.CrossRefGoogle Scholar
  41. 41.
    Reynolds MR, Neil N, Ho KK, et al. Clinical and economic outcomes of multivessel coronary stenting compared with bypass surgery: a single-center US experience. Am Heart J. 2003;145:334–42.CrossRefPubMedGoogle Scholar
  42. 42.
    Lingel JM, Srivastava MC, Gupta A. Management of coronary artery disease and acute coronary syndrome in the chronic kidney disease population—a review of the current literature. Hemodial Int. 2017;21:472–82.CrossRefPubMedGoogle Scholar
  43. 43.
    Ariyaratne TV, Ademi Z, Duffy SJ, et al. Cardiovascular readmissions and excess costs following percutaneous coronary intervention in patients with chronic kidney disease: data from a large multi-centre Australian registry. Int J Cardiol. 2013;168:2783–90.CrossRefPubMedGoogle Scholar
  44. 44.
    Sugumar H, Lancefield TF, Andrianopoulos N, et al. Impact of renal function in patients with multi-vessel coronary disease on long-term mortality following coronary artery bypass grafting compared with percutaneous coronary intervention. Int J Cardiol. 2014;172:442–9.CrossRefPubMedGoogle Scholar
  45. 45.
    Australian Commission on Safety and Quality in Health Care 2015, National core, hospital based outcome indicator specification, ACSQHC, Sydney. https://vwwv.safetyandguality.gov.au/wp-content/uploads/2015/06/National-core-hospital-based-outcome-indicators-consultation.pdf. Accessed 4 Dec 2016.

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Thathya V. Ariyaratne
    • 1
  • Zanfina Ademi
    • 1
    • 2
  • Molla Huq
    • 3
  • Franklin Rosenfeldt
    • 1
    • 4
  • Stephen J. Duffy
    • 1
    • 5
  • Bonny Parkinson
    • 6
  • Cheng-Hon Yap
    • 1
    • 7
  • Julian Smith
    • 8
  • Baki Billah
    • 1
  • Bryan P. Yan
    • 1
    • 9
  • Angela L. Brennan
    • 1
  • Lavinia Tran
    • 1
  • Christopher M. Reid
    • 1
    • 10
  1. 1.Department of Epidemiology and Preventive Medicine (DEPM), Centre of Cardiovascular Research and Education in Therapeutics (CCRE)Monash UniversityMelbourneAustralia
  2. 2.Institute of Pharmaceutical Medicine (ECPM)University of BaselBaselSwitzerland
  3. 3.Department of MedicineUniversity of MelbourneMelbourneAustralia
  4. 4.Baker Heart and Diabetes InstituteMelbourneAustralia
  5. 5.Department of Cardiovascular MedicineAlfred HospitalMelbourneAustralia
  6. 6.Macquarie University Centre for the Health EconomyMacquarie UniversitySydneyAustralia
  7. 7.Cardiothoracic UnitGeelong HospitalGeelongAustralia
  8. 8.Department of Surgery, School of Clinical Sciences, Monash HealthMonash UniversityMelbourneAustralia
  9. 9.Department of Medicine and Therapeutics, Faculty of MedicineChinese University of Hong KongShatinHong Kong
  10. 10.School of Public HealthCurtin UniversityPerthAustralia

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