Cost-Effectiveness of Coronary Artery Bypass Grafting (CABG) versus Percutaneous Coronary Intervention (PCI) as an add-on strategy to Optimal Medical Therapy (OMT) in Severe Ischemic Cardiomyopathy

Abstract

1.ABSTRACTBackgroundRevascularization through coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) as an add-on therapy to optimal medical therapy (OMT) is routinely used in patients with severe ischemic cardiomyopathy (ICM) with ejection fraction (EF) ≤ 35% to improve cardiovascular outcomes with limited available data about their relative costs and efficacies. We performed a cost-effectiveness analysis to illustrate the most economically favorable strategy in this population.MethodsA Markov model simulated a cohort with severe ICM (EF ≤ 35%) and evaluated strategies of CABG+OMT, PCI+OMT and OMT alone. Model inputs were obtained from STICHES and REVIVED clinical trials and their subsequent cost-effectiveness analyses. Cohorts were followed monthly, with mortality and major adverse cardiac events (MACE; a composite of heart failure hospitalization, myocardial infarction, revascularization and arrythmias) modeled as lifetime disutilities, taking the US health system perspective, and discounting 3%/year over lifetime horizon. Outcome measures were lifetime medical costs (2019 US$), quality-adjusted-life-years (QALYs), and incremental cost-effectiveness ratios (ICERs).ResultsOMT alone was the least costly strategy at $107,780 and yielded 5.29 QALYs. PCI+OMT yielded 4.87 QALYs and cost $121,368, while the CABG+OMT strategy resulted in 7.01 QALYs and cost $160,124 or $38,755 per QALY gained compared to PCI+OMT with an ICER of $18,130 per QALY gained over lifetime horizon. Thus, CABG+OMT was preferred at a $100,000/QALY gained threshold, a commonly cited US benchmark. In a probabilistic sensitivity analysis, CABG+OMT was the preferred strategy in 69%, 82% and 85%% of the model iterations at $50,000, $100,000, and $150,000 per QALY gained willingness-to-pay (WTP) thresholds respectively.ConclusionsCABG+OMT is the most cost-effective strategy in patients with severe ICM as compared with PCI+OMT or OMT only strategies at current benchmarks for value in the United States.WHAT IS KNOWNRevascularization though coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) are routinely used with optimal medical therapy to treat severe ischemic cardiomyopathy (ICM).The STICH (Surgical Treatment for Ischemic Heart Failure) trial demonstrated survival and economic superiority of CABG over OMT whereas the REVIVED (Revascularization for Ischemic Ventricular Dysfunction) trial showed no difference in clinical or economic outcomes between PCI and OMT groups in patients with ICM.Currently, no large-scale clinical trials have directly compared the health and economic outcomes of CABG versus PCI as adjunctive therapies to OMT in the ICM population. Consequently, their comparative cost-effectiveness remains unknown.WHAT THE STUDY ADDSThis study presents the first cost-effectiveness analysis comparing CABG+OMT versus PCI+OMT strategies in patients with severe ICM, addressing a significant knowledge gap.Results indicate that despite being more invasive and higher initial costs, CABG+OMT approach yields superior health outcomes and offers a financial advantage over the PCI+OMT strategy.This study identifies CABG+OMT as the most cost-effective strategy over PCI+OMT in severe ICM, thereby aiding decision-making for physicians and policymakers.