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Cost-Effectiveness of Percutaneous Coronary Intervention in Patients With Stable Coronary Artery Disease and Abnormal Fractional Flow Reserve
Study Questions:
How cost-effective is fractional flow reserve (FFR) guidance for percutaneous coronary intervention (PCI)?
Methods:
The authors assessed the cost-effectiveness of FFR-guided PCI using data from the FAME 2 (Fractional Flow Reserve Versus Angiography for Multivessel Evaluation 2) trial. This study demonstrated a significant reduction in subsequent coronary revascularization among patients with stable angina and at least one coronary lesion with a FFR ≤0.80, who were randomized to PCI compared with best medical therapy. The cost of the index hospitalization based on initial resource use and follow-up costs based on Medicare reimbursements were calculated. Patient utility was assessed using the EQ-5D health survey with US weights at baseline and 1 month and projected quality-adjusted life-years assuming a linear decline over 3 years in the 1-month utility improvements. Incremental cost-effectiveness ratio calculation was based on cumulative costs over 12 months.
Results:
Initial costs were significantly higher for FFR-guided PCI compared with medical therapy ($9,927 vs. $3,900, p < 0.001), but the $6,027 difference narrowed over 1-year follow-up to $2,883 (p < 0.001), mostly because of the cost of subsequent revascularization procedures. Patient utility was improved more at 1 month with PCI than with medical therapy (0.054 vs. 0.001 units, p < 0.001). The incremental cost-effectiveness ratio of PCI was $36,000 per quality-adjusted life-year, which was robust in sensitivity analyses.
Conclusions:
The authors concluded that FFR-guided PCI is cost-effective compared with best medical therapy.
Perspective:
This study demonstrated the cost-effectiveness of PCI compared with medical therapy for patients with FFR <0.8. This is in contrast to the COURAGE trial, where PCI was not cost-effective. The differing results of this study may reflect the superiority of FFR over angiography for guiding PCI, or may relate to factors unique to this trial. The FAME 2 trial was stopped prematurely, and may have overestimated the benefit of FFR-guided PCI. Nevertheless, the results provide additional support to use FFR to guide PCI of intermediate lesions in patients with stable angina pectoris.
Keywords: Coronary Artery Disease, Angina, Stable, Cardiology, Costs and Cost Analysis, Coronary Disease, Coronary Circulation, Angioplasty, Balloon, Coronary, Hospitalization, Quality-Adjusted Life Years, United States, Percutaneous Coronary Intervention
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