Cost-effectiveness of coronary artery bypass grafts versus percutaneous coronary intervention for revascularization of high-risk patients

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.