Cost-Effectiveness of Percutaneous Coronary Intervention in Patients with Stable Coronary Disease and Abnormal Fractional Flow Reserve
Background—The Fractional Flow Reserve versus Angiography for Multivessel Evaluation (FAME) 2 trial demonstrated a significant reduction in subsequent coronary revascularization among patients with stable angina and at least one coronary lesion with a fractional flow reserve (FFR) ≤0.80, who were randomized to percutaneous coronary intervention (PCI) as compared with best medical therapy. The economic and quality of life implications of PCI in the setting of an abnormal FFR are unknown.
Methods and Results—We calculated cost of the index hospitalization based on initial resource use and follow-up costs based on Medicare reimbursements. We assessed patient utility using the EQ-5D health survey with US weights at baseline and one month and projected quality adjusted life-years (QALY) assuming a linear decline over three years in the one month utility improvements. We calculated the incremental cost-effectiveness ratio based on cumulative costs over 12 months. Initial costs were significantly higher for PCI in the setting of an abnormal FFR compared with medical therapy ($9,927 vs. $3,900, p<0.001), but the $6,027 difference narrowed over one year follow-up to $2,883 (p<0.001), mostly due to the cost of subsequent revascularization procedures. Patient utility was improved more at one month with PCI compared with medical therapy (0.054 vs. 0.001 units, p<0.001). The incremental cost-effectiveness ratio of PCI was $36,000 per QALY, which was robust in bootstrap replications and in sensitivity analyses.
Conclusions—PCI of coronary lesions with reduced FFR improves outcomes and appears economically attractive compared with best medical therapy among patients with stable angina.
Clinical Trial Registration Information—ClinicalTrials.gov. Identifier: NCT01132495.
- Fractional Flow Reserve
- percutaneous coronary intervention
- medical therapy
- stable coronary artery disease
- Received April 11, 2013.
- Revision received July 5, 2013.
- Accepted August 5, 2013.