Poulin Frédéric, Rinfret Stéphane, Gobeil François
Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada.
Can J Cardiol. 2007 Dec;23(14):1139-45. doi: 10.1016/s0828-282x(07)70885-1.
Drug-eluting stents (DES) may promote percutaneous coronary intervention (PCI) procedures in patients traditionally referred for coronary artery bypass graft (CABG) surgery and may save money.
The purpose of the present study was to quantify the potential shift from CABG surgery to multivessel PCI in the DES era and to model the economic consequences.
Based on predefined criteria, the feasibility of PCI was evaluated in patients with multivessel coronary artery disease who underwent CABG surgery before the availability of DES at the Centre Hospitalier de l'Université de Montréal's Notre-Dame Hospital (Montreal, Quebec). Modelling was used to evaluate the potential cost savings using multivessel PCI instead of CABG surgery. Equal one-year outcomes in both groups were assumed, with the exception of a 10% repeat revascularization (RR) rate in the DES group and a 4% RR rate in the CABG group. The impact of those assumptions was evaluated using 1000 Monte Carlo simulations.
The authors retrospectively evaluated that, of 289 patients who underwent CABG without concomitant valve surgery between January and December 2003, only 22 patients (8%) were good candidates for multivessel DES implantation. The procedures would have involved an average of 3.6 DES per patient. The average cost per revascularization procedure was $14,402 with surgery and $11,220 for multivessel DES implantation (using $2,200 DES), leading to a savings of $3,182 per patient. However, after including RR procedures, PCI would only have been associated with savings of $812 per surgery avoided. Monte Carlo analysis revealed that surgery may be less expensive than PCI in 36% of patients.
Most patients who underwent CABG surgery in 2003 were retrospectively judged to be ineligible for multivessel PCI with DES. In the rare eligible patient, multivessel PCI with DES is not expected to produce savings to health care costs in Canada unless the DES purchase cost continues to decrease.
药物洗脱支架（DES）可能会推动经皮冠状动脉介入治疗（PCI）在传统上适合冠状动脉旁路移植术（CABG）的患者中应用，并且可能节省费用。
本研究的目的是量化DES时代从CABG手术向多支血管PCI潜在的转变，并对其经济后果进行建模。
基于预先设定的标准，在蒙特利尔大学圣母医院（魁北克省蒙特利尔）DES出现之前接受CABG手术的多支血管冠状动脉疾病患者中评估PCI的可行性。使用建模来评估使用多支血管PCI而非CABG手术可能节省的费用。假设两组的一年结局相同，但DES组的再次血运重建率（RR）为10%，CABG组为4%。使用1000次蒙特卡洛模拟评估这些假设的影响。
作者回顾性评估发现，在2003年1月至12月期间接受CABG且未同时进行瓣膜手术的289例患者中，只有22例（8%）是多支血管DES植入的合适人选。这些手术平均每位患者需要3.6个DES。手术每次血运重建的平均费用为14,402美元，多支血管DES植入为11,并植入（使用2,200美元的DES），每位患者节省3,182美元。然而，纳入RR手术后，避免每次手术PCI仅节省812美元。蒙特卡洛分析显示，36%的患者手术费用可能低于PCI。
回顾性判断，2003年接受CABG手术的大多数患者不符合多支血管DES PCI的条件。在极少数符合条件的患者中，除非DES购买成本持续下降，否则多支血管DES PCI预计不会为加拿大的医疗保健成本带来节省。
