Cost-Effectiveness of Percutaneous Coronary Intervention With Drug Eluting Stents Versus Bypass Surgery for Patients With Diabetes Mellitus and Multivessel Coronary Artery Disease: Results From the FREEDOM Trial

Study Questions:

What is the cost-effectiveness of percutaneous coronary intervention with drug-eluting stents (DES) versus coronary artery bypass grafting (CABG) for patients with diabetes mellitus and multivessel coronary artery disease in the FREEDOM trial?

Methods:

Between 2005 and 2010, 1,900 patients with diabetes mellitus and multivessel coronary artery disease were randomized to PCI with DES (DES-PCI; n = 953) or CABG (n = 947). Costs were assessed from the perspective of the US health care system. Health state utilities were assessed using the EuroQOL five-dimension three-level questionnaire. A patient-level microsimulation model based on US life-tables and in-trial results was used to estimate lifetime cost-effectiveness.

Results:

Although initial procedural costs were lower for CABG, total costs for the index hospitalization were $8,622 higher per patient. Over the next 5 years, follow-up costs were higher with PCI, owing to more frequent repeat revascularization and higher outpatient medication costs. Nonetheless, cumulative 5-year costs remained $3,641 higher per patient with CABG. Although there were only modest gains in survival with CABG during the trial period, when the in-trial results were extended to a lifetime horizon, CABG was projected to be economically attractive relative to DES-PCI, with substantial gains in both life expectancy and quality-adjusted life expectancy and incremental cost-effectiveness ratios <$10,000 per life-year or quality-adjusted life-year gained across a broad range of assumptions regarding the effect of CABG on post-trial survival and costs.

Conclusions:

The authors concluded that despite higher initial costs, CABG is a highly cost-effective revascularization strategy compared with DES-PCI for patients with diabetes mellitus and multivessel coronary artery disease.

Perspective:

The present study reports that although CABG was associated with an increase in initial costs of approximately $9,000/patient, these upfront costs were partially offset by lower costs in subsequent years principally as a result of a lower rate of repeat revascularization procedures and, to a lesser extent, less use of cardiac medications. Overall, it appears that CABG provides not only better long-term clinical outcomes than DES-PCI, but that these benefits are achieved at an overall cost that represents an attractive use of societal health care resources. These findings provide additional support for existing guidelines that recommend CABG as the preferred modality for diabetic patients with multivessel coronary artery disease.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Aortic Surgery, Interventions and Coronary Artery Disease

Keywords: Coronary Artery Disease, Drug-Eluting Stents, Coronary Artery Bypass, Diabetes Mellitus, Percutaneous Coronary Intervention


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