Abstract 3506: Cost Effectiveness of Adding PCI to Optimal Medical Therapy in Patients with Stable Coronary Artery Disease: Economic Outcomes from the COURAGE Trial

Abstract

Background: The main results of COURAGE showed no differences in all-cause mortality or non-fatal MI (primary endpoint), the composite of death, MI or stroke, or hospitalization for ACS (secondary endpoints) during 4.6 year median follow-up in the 2,287 patients with stable coronary artery disease (CAD) randomized to optimal medical therapy (OMT) with or without percutaneous coronary intervention (PCI). There was a benefit to PCI in quality of life measured with the Seattle Angina Questionnaire. This study focuses on cost-effectiveness of PCI. Methods: Resource utilization including initial and follow-up hospitalizations were assigned a DRG and then costs assigned from Medicare reimbursement. Medication costs were assessed from Redbook average wholesale price. Survival was estimated for patients from Framingham data. Survival was quality adjusted from utility measured by standard gamble. Cost and outcome were discounted 3%. Costs after the trial period are Medicare average costs. Cost-effectiveness is expressed as an incremental cost effectiveness ratio (ICER), of cost per life year (LY) or quality adjusted life year (QALY) gained. The distribution of the ICER was assessed by bootstrap. Results: The added cost of PCI is approximately $10,000, without significant gain in LY or QALYs. The ICER varied from just over $150,000 to just under $300,000 per LY or QALY gained with PCI. A large minority of the distributions of the ICERs found PCI to be dominated by OMT, that is OMT offering better outcome at lower cost. Conclusions: The addition of PCI to OMT as an initial management strategy costs significantly more without offering an advantage in survival or QALYs. The ICER is high compared to conventional benchmarks, and the distribution includes infinity and low probability of being below $50,000/QALY gained. PCI in addition to OMT is not a cost-effective initial management strategy for symptomatic, chronic coronary artery disease.