Abstract
AimsUsing bilateral internal thoracic arteries (BITAs) for coronary artery bypass grafting (CABG) has been suggested to improve survival compared to CABG using single internal thoracic arteries (SITAs) for patients with advanced coronary artery disease. We used data from the Arterial Revascularization Trial (ART) to assess long-term cost-effectiveness of BITA grafting compared to SITA grafting from an English health system perspective.Methods and resultsResource use, healthcare costs, and quality-adjusted life years (QALYs) were assessed across 10 years of follow-up from an intention-to-treat perspective. Missing data were addressed using multiple imputation. Incremental cost-effectiveness ratios were calculated with uncertainty characterized using non-parametric bootstrapping. Results were extrapolated beyond 10 years using Gompertz functions for survival and linear models for total cost and utility. Total mean costs at 10 years of follow-up were £17 594 in the BITA arm and £16 462 in the SITA arm [mean difference £1133 95% confidence interval (CI) £239 to £2026, P = 0.015]. Total mean QALYs at 10 years were 6.54 in the BITA arm and 6.57 in the SITA arm (adjusted mean difference −0.01 95% CI −0.2 to 0.1, P = 0.883). At 10 years, BITA grafting had a 33% probability of being cost-effective compared to SITA, assuming a cost-effectiveness threshold of £20 000. Lifetime extrapolation increased the probability of BITA being cost-effective to 51%.ConclusionsBITA grafting has significantly higher costs but similar quality-adjusted survival at 10 years compared to SITA grafting. Extrapolation suggests this could change over lifetime.
Highlights
The treatment of coronary artery disease places a large economic burden on health care systems, with a substantial proportion of that cost arising from Coronary Artery Bypass Grafting (CABG).[1]
Total mean quality-adjusted life-years (QALYs) at 10 years were 6.54 in the bilateral internal thoracic arteries (BITA) are and 6.57 in the single left internal thoracic artery (SITA) arm
Combining the cost and QALY differences, BITA is dominated by SITA
Summary
The treatment of coronary artery disease places a large economic burden on health care systems, with a substantial proportion of that cost arising from Coronary Artery Bypass Grafting (CABG).[1] CABG using a single left internal thoracic artery (SITA) has been found to improve long-term survival and quality of life (QoL) and to be cost-effective in comparison to the alternative of drug-eluting stents- percutaneous coronary intervention (DES-PCI) for patients with severe coronary disease and patients with diabetes in a Dutch context.[2]. A recent meta-analysis of 29 observational studies comparing BITA and SITA found BITA was associated with significantly improved long-term survival (HR 0.78).[3] no previous study has reported a comparison of quality of life, resource use and costs between SITA and BITA. An interim analysis of quality of life scores at 5 year found no significant differences between trial arms in the EQ-5D-3L, SF-36 or Shortened WHO Rose Angina Questionnaire.[7]
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