International Center for Health Outcomes and Innovation Research, the Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY.
Department of Cardiac Surgery, MedStar Heart & Vascular Institute, Washington, DC; Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Ga.
J Thorac Cardiovasc Surg. 2020 Jun;159(6):2230-2240.e15. doi: 10.1016/j.jtcvs.2019.06.040. Epub 2019 Jul 2.
The Cardiothoracic Surgical Trials Network reported that left ventricular reverse remodeling at 2 years did not differ between patients with moderate ischemic mitral regurgitation randomized to coronary artery bypass grafting plus mitral valve repair (n = 150) or coronary artery bypass grafting alone (n = 151). To address health resource use implications, we compared costs and quality-adjusted survival.
We used individual patient data from the Cardiothoracic Surgical Trials Network trial on survival, hospitalizations, quality of life, and US hospitalization costs to estimate cumulative costs and quality-adjusted life years. A microsimulation model was developed to extrapolate to 10 years. Bootstrap and deterministic sensitivity analyses were performed to address uncertainty.
In-hospital costs were $59,745 for coronary artery bypass grafting plus mitral valve repair versus $51,326 for coronary artery bypass grafting alone (difference $8419; 95% uncertainty interval, 2259-18,757). Two-year costs were $81,263 versus $67,341 (difference 13,922 [2370 to 28,888]), and quality-adjusted life years were 1.35 versus 1.30 (difference 0.05; -0.04 to 0.14), resulting in an incremental cost-effectiveness ratio of $308,343/quality-adjusted life year for coronary artery bypass grafting plus mitral valve repair. At 10 years, its costs remained higher ($107,733 vs $88,583, difference 19,150 [-3866 to 56,826]) and quality-adjusted life years showed no difference (-0.92 to 0.87), with 5.08 versus 5.08. The likelihood that coronary artery bypass grafting plus mitral valve repair would be considered cost-effective at 10 years based on a cost-effectiveness threshold of $100K/quality-adjusted life year did not exceed 37%. Only when this procedure reduces the death rate by a relative 5% will the incremental cost-effectiveness ratio fall below $100K/quality-adjusted life year.
The addition of mitral valve repair to coronary artery bypass grafting for patients with moderate ischemic mitral regurgitation is unlikely to be cost-effective. Only if late mortality benefits can be demonstrated will it meet commonly used cost-effectiveness criteria.
心胸外科学临床试验网络报告称，在随机接受冠状动脉旁路移植术加二尖瓣修复（n=150）或单纯冠状动脉旁路移植术（n=151）的中度缺血性二尖瓣反流患者中，2 年后左心室逆重构没有差异。为了解决卫生资源利用的影响，我们比较了成本和质量调整后的生存率。
我们使用来自心胸外科学临床试验网络试验的个体患者数据，包括生存率、住院率、生活质量和美国住院费用，以估计累积成本和质量调整生命年。建立了一个微观模拟模型来推断 10 年。进行了自举和确定性敏感性分析以解决不确定性。
冠状动脉旁路移植术加二尖瓣修复的住院费用为 59745 美元，而单纯冠状动脉旁路移植术为 51326 美元（差异 8419 美元；95%不确定性区间为 2259-18757 美元）。两年的成本分别为 81263 美元和 67341 美元（差异 13922 美元[2370 美元至 18757 美元]），质量调整生命年分别为 1.35 年和 1.30 年（差异 0.05 年[-0.04 年至 0.14 年]），因此冠状动脉旁路移植术加二尖瓣修复的增量成本效益比为 308343 美元/质量调整生命年。在 10 年时，其成本仍然较高（107733 美元对 88583 美元，差异 19150 美元[-3866 美元至 56826 美元]），质量调整生命年没有差异（-0.92 年至 0.87 年），为 5.08 年。基于 100K/质量调整生命年的成本效益阈值，冠状动脉旁路移植术加二尖瓣修复在 10 年内被认为具有成本效益的可能性不超过 37%。只有当该手术能使死亡率相对降低 5%时，增量成本效益比才会低于 100K/质量调整生命年。
对于中度缺血性二尖瓣反流患者，在冠状动脉旁路移植术上加二尖瓣修复不太可能具有成本效益。只有当晚期死亡率获益能够得到证明时，它才符合常用的成本效益标准。
