Cost-effectiveness of coronary angioplasty versus medical treatment: the impact of cost-shifting

Medical therapy versus percutaneous coronary intervention in ischemic heart disease: A cost-effectiveness analysis

Background: Ischemic heart disease is categorized into two acute and chronic groups, and its treatments include revascularization and medical therapy. The aim of this study is to evaluate the economic burden of medical therapy compared to percutaneous coronary intervention in ischemic heart disease.

Methods: This study has been done in two steps. The first was a systematic review and meta-analysis to measure the effectiveness of two interventions and the second step was a cost-effectiveness analysis from the perspective of society. The data analysis included a meta-analysis and the Markov cohort simulation. RewMan v5 and tree age software were utilized. Uncertainties related to the model parameters were evaluated using one-way and two-way sensitivity analyses.

Results: Regarding the effectiveness of interventions, the odd ratio of the quality of life in the medical therapy group (CI: 0.76-1.10) was 0.91 times the PCI group (p=0.34). This rate for mortality in medical therapy (CI: 0.52-9.68) was 2.23 times more than the PCI group; this result was not significant (p=0.02). In the cost-effectiveness analysis, the cost-effectiveness threshold was $ 16,482; ICER in increasing the QoL and reduction in the mortality rate was $ 25320.11 and $ 562.6691, respectively. Regarding the sensitivity analysis, the model was not sensitive in changing parameters in a specific domain.

Conclusion: According to this study, PCI is more cost-effective than medical therapy in the reduction of mortality rate and in the field of increasing quality of life. MT strategy is more cost-effective than the PCI. This study considers controversies regarding the most appropriate treatment for patients with ischemic heart disease that is helpful for health policymakers, cardiologists and health managers.

Treatment for stable coronary artery disease: a network meta-analysis of cost-effectiveness studies

Introduction and Objectives

Numerous studies have assessed cost-effectiveness of different treatment modalities for stable angina. Direct comparisons, however, are uncommon. We therefore set out to compare the efficacy and mean cost per patient after 1 and 3 years of follow-up, of the following treatments as assessed in randomized controlled trials (RCT): medical therapy (MT), percutaneous coronary intervention (PCI) without stent (PTCA), with bare-metal stent (BMS), with drug-eluting stent (DES), and elective coronary artery bypass graft (CABG).

Methods

RCT comparing at least two of the five treatments and reporting clinical and cost data were identified by a systematic search. Clinical end-points were mortality and myocardial infarction (MI). The costs described in the different trials were standardized and expressed in US $ 2008, based on purchasing power parity. A network meta-analysis was used to compare costs.

Results

Fifteen RCT were selected. Mortality and MI rates were similar in the five treatment groups both for 1-year and 3-year follow-up. Weighted cost per patient however differed markedly for the five treatment modalities, at both one year and three years (P<0.0001). MT was the least expensive treatment modality: US $3069 and 13 864 after one and three years of follow-up, while CABG was the most costly: US $27 003 and 28 670 after one and three years. PCI, whether with plain balloon, BMS or DES came in between, but was closer to the costs of CABG.

Conclusions

Appreciable savings in health expenditures can be achieved by using MT in the management of patients with stable angina.

Estimating utility data from clinical indicators for patients with stable angina

This study estimated a model from which data routinely collected in clinical trials of angina patients can be mapped to a utility scale and used to estimate quality-adjusted life years (QALYs). Patients with stable angina attending four cardiac out-patient clinics in the UK were included in the study. Data collected included information on patients' health-related quality of life (HRQL) using the EQ-5D, and severity of angina symptoms using two cardiac-specific measures [Breathlessness Grade and Canadian Cardiovascular Society (CCS) classification of angina]. Regression analysis was used to predict EQ-5D index values from the data. Data were obtained from 510 patients. For CCS grades, mean EQ-5D scores ranged from 0.36 (95% confidence interval 0.25-0.48) for grade 4 to 0.81 (0.77-0.85) for grade 0, and for breathlessness grades, EQ-5D scores ranged from 0.31 (0.06-0.55) for grade 0 to 0.84 (0.79-0.88) for grade 5. The final model used data on CCS grades, breathlessness grades, and patients' current medications to predict EQ-5D scores. The model had an R2 value of 0.37, and predictions for less severe angina were considered more reliable than the estimates for severe angina. In the absence of utility data collected as part of a clinical trial it is possible to map HRQL utility data from samples of patients with similar characteristics to those in the original trial. The uncertainty surrounding the estimates should be considered when using the results to estimate QALYs for purposes of economic evaluation.

Comparing systems for costing hospital treatments. The case of stable angina pectoris

This paper demonstrates the basic properties in the systems most commonly considered for costing treatments in the Danish hospitals. The differences between the traditional charge system, the DRG system and the ABC system are analysed, and difficulties encountered in comparing these systems are discussed. A sample of patients diagnosed with stable angina pectoris (SAP) at Odense University Hospital was used to compare the three systems when costing an entire treatment path, costing single hospitalisations and studying the effects of length of stay. Furthermore, it is illustrated that the main idea behind each system is reflected in how the systems over- or underestimate costs. Implications when managing the hospitals, particularly reimbursement, are discussed.

Impact of an aggressive stenting strategy on initial and one-year follow-up costs in patients undergoing coronary angioplasty

BACKGROUND

Although stents have been shown in randomised trials to reduce restenosis rates compared with balloon angioplasty, there are concerns regarding the cost-effectiveness of an aggressive stenting strategy. Stents were shown to increase medical costs over 12 months in the early trials.

AIM

Our aim was to determine the economic impact of an aggressive stenting strategy using current stenting techniques compared with a conservative stenting strategy.

METHODS

Initial and one year follow-up costs were determined in all patients who underwent successful revascularisation during June to December 1996 (aggressive stenting, n = 401), and compared to all patients treated in the corresponding months in 1995 (conservative stenting, n = 347). All patients had clinical follow-up for one year.

RESULTS

The proportion of patients receiving a stent increased from 22.5% in 1995 to 66.1% in 1996 (p < 0.0001). Requirement for repeat procedures in the 1995 group compared with 1996 was coronary angiography in 31% vs 16% (p < 0.001), coronary angioplasty in 11% vs 6% (p = 0.0044) and bypass surgery in 4.8% vs 2.5% (p = 0.054). The mean initial cost of the procedure was higher in the aggressive stenting group ($4319 +/- 1276 in 1995 vs $5131 +/- 1491 in 1996, p < 0.0001), but after 12 months follow-up, total medical costs were equivalent ($5975 +/- 4143 in 1995 vs $5994 +/- 3476 in 1996, p = NS).

CONCLUSION

An aggressive coronary stenting strategy is associated with higher initial costs compared with a conservative strategy, but lower costs during follow-up due to reduced need for repeat procedures, resulting in equivalent one year total medical costs.