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CABG more cost effective than PCI for patients with diabetes
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LOS ANGELES — Although the initial cost of CABG was higher than PCI, 5-year follow-up suggests that the improved clinical outcomes associated with the procedure in patients with diabetes and multivessel CAD leads to lower long-term costs, according to a cost-effectiveness analysis of the FREEDOM trial.
“This prospective economic evaluation was carried out alongside the FREEDOM trial to provide additional insight into the relative value of CABG vs. PCI in the drug-eluting stent era from the perspective of the US health care system,” Elizabeth A. Magnuson, ScD, of Saint Luke’s Mid American Heart Institute in Kansas City, Mo., said at a press conference.
Due to the prolonged recovery period and higher complication rates, the initial cost of CABG was $8,622 higher than PCI (P<.001). During 5 years of follow-up, high rates of resource use in the PCI arm, largely due to a greater number of repeat revascularization procedures and CV hospitalizations, significantly increased costs associated with the procedure. After accounting for these added costs, CABG costs remained $3,600 higher, according to Magnuson.
Patients who underwent CABG, however, had lower risk for death or MI compared with those in the PCI group. CABG was associated with 0.66 quality-adjusted life-years gained and higher costs of approximately $5,400 per patient. Lifetime cost effectiveness of CABG was therefore $8,132 per QALY gained, significantly lower than the commonly used benchmark of $50,000 per QALY gained for considering a treatment to be cost effective, Magnuson said.
“For patients with diabetes and multivessel CAD, CABG provides not only better long-term clinical outcomes than PCI with DES, but these benefits are achieved at an overall cost that represents an attractive use of societal health care resources. These findings provide additional support for existing guidelines that recommend CABG for diabetic patients with multivessel CAD,” she said.
The FREEDOM trial was a 5-year, randomized, superiority trial in which the clinical outcomes of CABG were compared with PCI using a DES in patients with diabetes and multivessel CAD. The in-trial analysis reported by Magnuson was based on observed survival, health state utility and costs derived from observed health care resource use through 5 years and a lifetime analysis based on projections of survival, quality-adjusted survival and costs beyond 5 years. – by Melissa Foster
For more information:
Magnuson EA. Late-breaking clinical trials: Health economics and quality of life in contemporary trials. Presented at: the American Heart Association Scientific Sessions 2012; Nov. 3-7, 2012; Los Angeles.
Disclosure: Magnuson reports receiving research grants from Abbott Vascular, AstraZeneca, Boston Scientific, Daiichi Sankyo, Edwards Lifesciences, Eli Lilly and Medtronic.
Perspective
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Mark Hlatky, MD
Whenever you do a cost-effectiveness analysis in a trial, especially involving surgery, you have the chance to see all of the costs upfront during the trial period, but the full benefits of treatment may not be seen during the trial period. This is particularly so in FREEDOM because the costs of the survival curves didn’t separate until late. Many patients died, but we only saw part of their life expectancy loss during the trial, which is why the [researchers] did a projection of this.
I want to underscore that the most important part of this projection is not some fancy prediction about the future but a full accounting of what actually happened to the patients observed — in other words, patients who died during the trial. If each one of these patients had would have lived another 12 years, we can calculate that the cost-effectiveness ratio during the trial would be much more favorable than it was at the long-term projection. So, I think the cost-effectiveness results are quite solid. Essentially, the researchers found that the observed differences in survival that were seen in the trial, coupled with the cost difference of about $3,600, makes [CABG] look like a very economically attractive therapy for patients who have diabetes.
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