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Cost-effectiveness of percutaneous coronary intervention with drug-eluting stents versus bypass surgery for patients with 3-vessel or left main coronary artery disease: final results from the Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery (SYNTAX) trial.

AbstractBACKGROUND:
The Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery (SYNTAX) trial demonstrated that in patients with 3-vessel or left main coronary artery disease, coronary artery bypass graft surgery (CABG) was associated with a lower rate of cardiovascular death, myocardial infarction, stroke, or repeat revascularization compared with percutaneous coronary revascularization with drug-eluting stents (DES-PCI)). The long-term cost-effectiveness of these strategies is unknown.
METHODS AND RESULTS:
Between 2005 and 2007, 1800 patients with left main or 3-vessel coronary artery disease were randomized to CABG (n=897) or DES-PCI (n=903). Costs were assessed from a US perspective, and health state utilities were evaluated with the EuroQOL questionnaire. A patient-level microsimulation model based on the 5-year in-trial data was used to extrapolate costs, life expectancy, and quality-adjusted life expectancy over a lifetime horizon. Although initial procedural costs were $3415 per patient lower with CABG, total hospitalization costs were $10 036 per patient higher. Over the next 5 years, follow-up costs were higher with DES-PCI as a result of more frequent hospitalizations, revascularization procedures, and higher medication costs. Over a lifetime horizon, CABG remained more costly than DES-PCI, but the incremental cost-effectiveness ratio was favorable ($16 537 per quality-adjusted life-year gained) and remained <$20 000 per quality-adjusted life-year in most bootstrap replicates. Results were consistent across a wide range of assumptions about the long-term effect of CABG versus DES-PCI on events and costs. In patients with left main disease or a SYNTAX score ≤22, however, DES-PCI was economically dominant compared with CABG, although these findings were less certain.
CONCLUSIONS:
For most patients with 3-vessel or left main coronary artery disease, CABG is a clinically and economically attractive revascularization strategy compared with DES-PCI. However, among patients with less complex disease, DES-PCI may be preferred on both clinical and economic grounds.
CLINICAL TRIAL REGISTRATION URL:
www.clinicaltrials.gov. Unique identifier: NCT00114972.
AuthorsDavid J Cohen, Ruben L Osnabrugge, Elizabeth A Magnuson, Kaijun Wang, Haiyan Li, Khaja Chinnakondepalli, Duane Pinto, Mouin S Abdallah, Katherine A Vilain, Marie-Claude Morice, Keith D Dawkins, A Pieter Kappetein, Friedrich W Mohr, Patrick W Serruys, SYNTAX Trial Investigators
JournalCirculation (Circulation) Vol. 130 Issue 14 Pg. 1146-57 (Sep 30 2014) ISSN: 1524-4539 [Electronic] United States
PMID25085960 (Publication Type: Comparative Study, Journal Article, Randomized Controlled Trial, Research Support, Non-U.S. Gov't)
Copyright© 2014 American Heart Association, Inc.
Topics
  • Aged
  • Ambulatory Care (economics)
  • Coronary Artery Bypass (economics, methods, mortality)
  • Coronary Artery Disease (economics, mortality, surgery)
  • Coronary Vessels (surgery)
  • Cost-Benefit Analysis
  • Drug-Eluting Stents (economics, statistics & numerical data)
  • Female
  • Hospital Costs
  • Humans
  • Male
  • Middle Aged
  • Percutaneous Coronary Intervention (economics, methods, mortality)
  • Physicians (economics)
  • Quality of Life
  • Quality-Adjusted Life Years
  • Treatment Outcome

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