Department of Epidemiology and Preventive Medicine (DEPM), Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, 6th Floor, 99 Commercial Rd, Melbourne, VIC, 3004, Australia.
Institute of Pharmaceutical Medicine (ECPM), University of Basel, Basel, Switzerland.
Appl Health Econ Health Policy. 2018 Oct;16(5):661-674. doi: 10.1007/s40258-018-0407-5.
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.
在当代常规临床实践中，比较冠状动脉旁路移植术（CABG）和经皮冠状动脉介入治疗（PCI）治疗多支血管冠状动脉疾病（MVCAD）的经济评估有限。
旨在使用观察性数据源，从澳大利亚公立医院支付者的角度，对 MVCAD 患者的 CABG 和 PCI 进行成本效益分析。
对 2009 年 6 月至 2013 年 12 月期间进行的 1022 例 CABG（治疗）和 978 例 PCI（对照）手术的墨尔本介入组（MIG）和澳大利亚和新西兰心胸外科医师学会（ANZSCTS）登记处的临床数据进行了分析。将临床记录与同一医院的住院记录和国家死亡指数（NDI）数据进行了关联。评估每避免一次主要不良心脏和脑血管事件（MACCE）的增量成本效益比（ICER）。采用倾向评分箱式 bootstrap（PSBB）方法验证基本案例结果。
在平均 2.7 年的随访中，CABG 与 PCI 相比，费用增加，全因死亡率更高，但 MACCE 发生率显著降低。在整个队列中，观察到每避免一次 MACCE 的 ICER 为 55255 澳元（澳大利亚元）。该 ICER 因与裸金属支架（ICER 为 25815 澳元/MACCE 避免）、所有药物洗脱支架（DES）（ICER 为 56861 澳元）、第二代 DES（ICER 为 42925 澳元）和第三代 DES（ICER 为 88535 澳元）的比较而有所不同。对于高危亚组，包括慢性肾脏病（ICER 为 62299 澳元）、糖尿病（ICER 为 42819 澳元）、心肌梗死史（ICER 为 30431 澳元）、左主干冠状动脉疾病（ICER 为 38864 澳元）和心力衰竭（ICER 为 36966 澳元），中等至低的 ICER 很明显。
在早期随访中，与 PCI 相比，CABG 治疗高危亚组的 ICER 低于整个队列。采用个体化、多学科的治疗方法可能有助于控制成本，同时改善血运重建策略后的临床结果。
