Gorenoi Vitali, Dintsios Charalabos-Markos, Schönermark Matthias P, Hagen Anja
Abteilung für Epidemiologie, Sozialmedizin und Gesundheitssystemforschung, Medizinische Hochschule Hannover, Carl-Neuberg-Strasse, 30625 Hannover.
Herz. 2009 May;34(3):231-9. doi: 10.1007/s00059-009-3182-0. Epub 2009 May 16.
The therapy of coronary heart disease (CHD) leads to an enormous economic burden on health-care systems. Coronary artery bypass grafting (CABG) and percutaneous revascularizations with implantation of drug-eluting stents (DES) are important treatment methods in CHD. The presented evaluation addresses cost efficacy of the use of DES versus CABG in CHD patients.
A health-economic model considering linear resource use was performed from a restricted societal perspective for time periods of 1 and 3 years. Because of the short time horizon discounting was not applied. The clinical assumptions for event rates at 1 and 3 years were derived from the ARTS-I study for CABG, and from the ARTS-II study for DES (sirolimus-eluting stents). Cost assumptions for the resources used were based on the German Diagnosis Related Groups 2007 (G-DRG-2007). The base case value was assumed to be 2,800 Euros, the average DES price 1,200 Euros, and the average DES use per patient 3.7. The average per-patient daily clopidogrel costs were assumed to be 2.57 Euros, and the duration of the clopidogrel therapy 12 months. Within the scope of sensitivity analyses, different model parameters were varied and the evaluation was tested for its robustness.
The average costs for percutaneous coronary intervention (PCI) without DES were found to be 4,420 Euros, for CABG 12,840 Euros, and for DES intervention 8,860 Euros (Table 4). 1-year clopidogrel intake resulted in 938 Euros, the treatment of patients with myocardial infarction during follow-up in 3,989 Euros. The 1-year per-patient total costs after CABG were calculated to be 13,373 Euros and after DES 10,443 Euros, leading to a difference of 2,930 Euros in favor of DES implantation (Table 6). The 3-year per-patient total costs after CABG were estimated to be 13,630 Euros and after DES 10,905 Euros, showing a Rehabilitationsmasscost difference of 2,725 Euros in favor of DES implantation (Table 6). Changes in cost-weights of G-DRG-2007 for CABG and PCI, DES price and DES use per patient as well as in the duration of the clopidogrel therapy influenced the cost differences considerably; however, they did not reach a break-even point (Figures 2 and 3). Changes in the clinical follow-up assumptions showed a lower effect on the difference in total costs (Figures 2 and 3).
The presented data, indicating a possible economic middle-term advantage of DES versus CABG, should be proven with clinical assumptions derived from randomized clinical trials.
冠心病（CHD）的治疗给医疗保健系统带来了巨大的经济负担。冠状动脉旁路移植术（CABG）和药物洗脱支架（DES）植入的经皮血管重建术是冠心病的重要治疗方法。本评估探讨了冠心病患者使用DES与CABG的成本效益。
从有限的社会角度出发，构建了一个考虑线性资源使用的健康经济模型，时间跨度为1年和3年。由于时间跨度较短，未应用贴现。1年和3年事件发生率的临床假设源自ARTS - I研究（针对CABG）以及ARTS - II研究（针对DES，西罗莫司洗脱支架）。所使用资源的成本假设基于2007年德国诊断相关分组（G - DRG - 2007）。基础病例值假定为2800欧元，DES平均价格为1200欧元，每位患者平均使用DES数量为3.7个。每位患者每日氯吡格雷平均成本假定为2.57欧元，氯吡格雷治疗持续时间为12个月。在敏感性分析范围内，对不同模型参数进行了变化，并测试了评估的稳健性。
发现无DES的经皮冠状动脉介入治疗（PCI）平均成本为4420欧元，CABG为12840欧元，DES介入为8860欧元（表4）。1年氯吡格雷摄入导致成本为938欧元，随访期间心肌梗死患者治疗成本为3989欧元。CABG术后每位患者1年总成本计算为13373欧元，DES术后为10443欧元，DES植入具有2930欧元的优势（表6）。CABG术后每位患者3年总成本估计为13630欧元，DES术后为10905欧元，DES植入在康复质量成本方面具有2725欧元的优势（表6）。G - DRG - 2007中CABG和PCI、DES价格、每位患者DES使用数量以及氯吡格雷治疗持续时间的成本权重变化对成本差异有很大影响；然而，它们未达到盈亏平衡点（图2和图3）。临床随访假设的变化对总成本差异的影响较小（图2和图3）。
所呈现的数据表明DES相对于CABG可能具有中期经济优势，这一结论应由来自随机临床试验的临床假设加以证实。
