844 Intravascular Ultrasound Versus Angiography-Guided Drug-Eluting Stent Implantation: A Health Economic Analysis

Abstract

There is increasing evidence that use of intravascular ultrasound (IVUS) guidance during percutaneous coronary intervention (PCI) is associated with improved clinical outcomes compared with angiography alone. However, concern regarding the cost-effectiveness of IVUS has limited use of this technology worldwide. In this study, we aimed to evaluate the cost-effectiveness of IVUS-guided PCI compared with angiography-guided PCI in patients undergoing drug-eluting stent (DES) implantation. A Markov model was constructed to compare the cost-effectiveness of IVUS-guided to angiography-guided DES implantation from the Australian healthcare system perspective. Procedure-related morbidity and mortality were estimated from the published literature. Costs were obtained from Australian sources. Outcomes of interest included costs, life-expectancy and quality-adjusted life years (QALYs). In the base case analysis, the population of interest was all-comers undergoing PCI. In sensitivity analyses, we explored whether lesion subtype affected cost-effectiveness. In the base case, IVUS-guided DES implantation was cost-effective compared to angiography-guided DES implantation. With 5% annual discounting, IVUS was associated with increased lifetime costs of AUD$799 per person and benefits of 0.10 life-years and 0.11 QALYs compared to angiography, yielding an incremental cost-effectiveness ratio of AUD$9,280/QALY gained. Analysis by lesion subtype revealed greater cost-effectiveness among patients with left main and complex coronary lesions. Results were robust to sensitivity analyses, with IVUS being cost-effective in 98% of 10,000 Monte Carlo iterations assuming a willingness-to-pay threshold of $AUD50,000/QALY gained. Use of IVUS guidance during PCI is likely to be cost-effective compared with angiography guidance alone among patients undergoing DES implantation.