Published Online
on September 11, 2006

A more recent version of this article appeared on September 19, 2006

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Submitted on June 22, 2005
Revised on June 23, 2006
Accepted on June 27, 2006

Cost-Effectiveness of Coronary Artery Bypass Grafts Versus Percutaneous Coronary Intervention for Revascularization of High-Risk Patients

Kevin T. Stroupe PhD^*, Douglass A. Morrison MD, PhD, Mark A. Hlatky MD, Paul G. Barnett PhD, Lishan Cao MS, Christopher Lyttle MA, Denise M. Hynes RN, PhD, William G. Henderson PhD, for the Investigators of Veterans Affairs Cooperative Studies Program #385 (AWESOME: Angina With Extremely Serious Operative Mortality Evaluation)

From the Cooperative Studies Program Coordinating Center (K.T.S.), Hines VA Hospital, Hines, Ill; Midwest Center for Health Services and Policy Research (K.T.S., D.M.H.), Hines VA Hospital, Hines, Ill; Feinberg School of Medicine (K.T.S., L.C., C.L.), Chicago, Ill; VA Information Resource Center (K.T.S., D.M.H.), Hines, Ill; Tucson VA Medical Center (D.A.M.), Tucson, Ariz; University of Arizona (D.A.M.), Tucson, Ariz; Stanford University School of Medicine (M.A.H., P.G.B.), Stanford, Calif; VA Health Economics Resource Center (P.G.B.), Menlo Park, Calif; VA Cooperative Studies Program Coordinating Center (P.G.B.), Palo Alto, Calif; Loyola University Chicago (D.M.H.), Maywood, Ill; and University of Colorado Health Outcomes Program (W.G.H.), Aurora, Col.

^* To whom correspondence should be addressed. E-mail: Kevin.Stroupe{at}va.gov.

Background--A Department of Veterans Affairs Cooperative Study randomized high-risk patients with medically refractory myocardial ischemia, a group largely excluded from previous trials, to urgent revascularization with either percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). The present study examined the cost-effectiveness of PCI versus CABG for these high-risk patients.

Methods and Results--Of 454 patients at 16 Department of Veterans Affairs medical centers, 445 were available for the economic analysis (218 PCI and 227 CABG patients). Total costs were assessed at 3 and 5 years from the third-party payer’s perspective, and effectiveness was measured by survival. After 3 years, average total costs were $63 896 for PCI versus $84 364 for CABG patients, a difference of $20 468 (95% confidence interval [CI] $13 918 to $27 569). CIs were estimated by bootstrapping. Survival at 3 years was 0.82 for PCI versus 0.79 for CABG patients (P=0.34). Precision of the cost-effectiveness estimates were assessed by bootstrapping. PCI was less costly and more effective at 3 years in 92.6% of the bootstrap replications. After 5 years, average total costs were $81 790 for PCI versus $100 522 for CABG patients, a difference of $18 732 (95% CI $9873 to $27 831), whereas survival at 5 years was 0.75 for PCI patients versus 0.70 for CABG patients (P=0.21). At 5 years, PCI remained less costly and more effective in 89.4% of the bootstrap replications.

Conclusions--PCI was less costly and at least as effective for the urgent revascularization of medically refractory, high-risk patients over 5 years.

Key words: revascularization • bypass • angioplasty • cost-benefit analysis

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