Bart S Ferket1, Vinod H Thourani2, Pierre Voisine3, Samuel F Hohmann4, Helena L Chang1, Peter K Smith5, Robert E Michler6, Gorav Ailawadi7, Louis P Perrault8, Marissa A Miller9, Karen O'Sullivan1, Stephanie L Mick10, Emilia Bagiella1, Michael A Acker11, Ellen Moquete1, Judy W Hung12, Jessica R Overbey1, Anuradha Lala1, Margaret Iraola13, James S Gammie14, Annetine C Gelijns15, Patrick T O'Gara16, Alan J Moskowitz1. 1. International Center for Health Outcomes and Innovation Research, the Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY. 2. Department of Cardiac Surgery, MedStar Heart & Vascular Institute, Washington, DC; Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Ga. 3. Institut Universitaire de Cardiologie et Pneumonologie de Québec, Hôpital Laval, Québec, Quebec, Canada. 4. Center for Advanced Analytics, Vizient, Chicago, Ill. 5. Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC. 6. Department of Cardiothoracic and Vascular Surgery, Department of Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, New York, NY. 7. Division of Thoracic and Cardiovascular Surgery, University of Virginia School of Medicine, Charlottesville, Va. 8. Montréal Heart Institute, University of Montréal, Montréal, Quebec, Canada. 9. Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, Md. 10. Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio. 11. Department of Surgery, Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pa. 12. Division of Cardiology, Massachusetts General Hospital, Boston, Mass. 13. Cardiovascular Services, Suburban Hospital of Johns Hopkins Medicine, Bethesda, Md. 14. Department of Surgery, Division of Cardiac Surgery, University of Maryland Medical Center, Baltimore, Md. 15. International Center for Health Outcomes and Innovation Research, the Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY. Electronic address: annetine.gelijns@mssm.edu. 16. Cardiovascular Division, Brigham and Women's Hospital, Boston, Mass.
Abstract
OBJECTIVE: The Cardiothoracic Surgical Trials Network reported that left ventricular reverse remodeling at 2 years did not differ between patients with moderate ischemic mitral regurgitation randomized to coronary artery bypass grafting plus mitral valve repair (n = 150) or coronary artery bypass grafting alone (n = 151). To address health resource use implications, we compared costs and quality-adjusted survival. METHODS: We used individual patient data from the Cardiothoracic Surgical Trials Network trial on survival, hospitalizations, quality of life, and US hospitalization costs to estimate cumulative costs and quality-adjusted life years. A microsimulation model was developed to extrapolate to 10 years. Bootstrap and deterministic sensitivity analyses were performed to address uncertainty. RESULTS: In-hospital costs were $59,745 for coronary artery bypass grafting plus mitral valve repair versus $51,326 for coronary artery bypass grafting alone (difference $8419; 95% uncertainty interval, 2259-18,757). Two-year costs were $81,263 versus $67,341 (difference 13,922 [2370 to 28,888]), and quality-adjusted life years were 1.35 versus 1.30 (difference 0.05; -0.04 to 0.14), resulting in an incremental cost-effectiveness ratio of $308,343/quality-adjusted life year for coronary artery bypass grafting plus mitral valve repair. At 10 years, its costs remained higher ($107,733 vs $88,583, difference 19,150 [-3866 to 56,826]) and quality-adjusted life years showed no difference (-0.92 to 0.87), with 5.08 versus 5.08. The likelihood that coronary artery bypass grafting plus mitral valve repair would be considered cost-effective at 10 years based on a cost-effectiveness threshold of $100K/quality-adjusted life year did not exceed 37%. Only when this procedure reduces the death rate by a relative 5% will the incremental cost-effectiveness ratio fall below $100K/quality-adjusted life year. CONCLUSIONS: The addition of mitral valve repair to coronary artery bypass grafting for patients with moderate ischemic mitral regurgitation is unlikely to be cost-effective. Only if late mortality benefits can be demonstrated will it meet commonly used cost-effectiveness criteria.
OBJECTIVE: The Cardiothoracic Surgical Trials Network reported that left ventricular reverse remodeling at 2 years did not differ between patients with moderate ischemic mitral regurgitation randomized to coronary artery bypass grafting plus mitral valve repair (n = 150) or coronary artery bypass grafting alone (n = 151). To address health resource use implications, we compared costs and quality-adjusted survival. METHODS: We used individual patient data from the Cardiothoracic Surgical Trials Network trial on survival, hospitalizations, quality of life, and US hospitalization costs to estimate cumulative costs and quality-adjusted life years. A microsimulation model was developed to extrapolate to 10 years. Bootstrap and deterministic sensitivity analyses were performed to address uncertainty. RESULTS: In-hospital costs were $59,745 for coronary artery bypass grafting plus mitral valve repair versus $51,326 for coronary artery bypass grafting alone (difference $8419; 95% uncertainty interval, 2259-18,757). Two-year costs were $81,263 versus $67,341 (difference 13,922 [2370 to 28,888]), and quality-adjusted life years were 1.35 versus 1.30 (difference 0.05; -0.04 to 0.14), resulting in an incremental cost-effectiveness ratio of $308,343/quality-adjusted life year for coronary artery bypass grafting plus mitral valve repair. At 10 years, its costs remained higher ($107,733 vs $88,583, difference 19,150 [-3866 to 56,826]) and quality-adjusted life years showed no difference (-0.92 to 0.87), with 5.08 versus 5.08. The likelihood that coronary artery bypass grafting plus mitral valve repair would be considered cost-effective at 10 years based on a cost-effectiveness threshold of $100K/quality-adjusted life year did not exceed 37%. Only when this procedure reduces the death rate by a relative 5% will the incremental cost-effectiveness ratio fall below $100K/quality-adjusted life year. CONCLUSIONS: The addition of mitral valve repair to coronary artery bypass grafting for patients with moderate ischemic mitral regurgitation is unlikely to be cost-effective. Only if late mortality benefits can be demonstrated will it meet commonly used cost-effectiveness criteria.
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