Derek S Chew1,2,3, Patricia A Cowper1, Hussein Al-Khalidi1,4, Kevin J Anstrom1,4, Melanie R Daniels1, Linda Davidson-Ray1, Yanhong Li1, Robert E Michler5, Julio A Panza6, Ileana L Piña7, Jean L Rouleau8, Eric J Velazquez9, Daniel B Mark1,10. 1. Duke Clinical Research Institute (D.S.C., P.A.C., H.A., K.J.A., M.R.D., L.D.-R., Y.L., D.B.M.), Duke University, Durham, NC. 2. Department of Cardiac Sciences, Libin Cardiovascular Institute (D.S.C.), University of Calgary, Alberta, Canada. 3. O'Brien Institute for Public Health (D.S.C.), University of Calgary, Alberta, Canada. 4. Department of Biostatistics and Bioinformatics (H.A., K.J.A.), Duke University, Durham, NC. 5. Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Bronx, NY (R.E.M.). 6. Department of Cardiology, Westchester Medical Center, Westchester Medical Center Health Network, Valhalla, NY (J.A.P.). 7. Department of Medicine, Wayne State University, Detroit, MI (I.L.P.). 8. Institut de Cardiologie de Montréal, Université de Montréal, Canada (J.L.R.). 9. Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT (E.J.V.). 10. Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC (D.B.M.).
Abstract
BACKGROUND: The STICH Randomized Clinical Trial (Surgical Treatment for Ischemic Heart Failure) demonstrated that coronary artery bypass grafting (CABG) reduced all-cause mortality rates out to 10 years compared with medical therapy alone (MED) in patients with ischemic cardiomyopathy and reduced left ventricular function (ejection fraction ≤35%). We examined the economic implications of these results. METHODS: We used a decision-analytic patient-level simulation model to estimate the lifetime costs and benefits of CABG and MED using patient-level resource use and clinical data collected in the STICH trial. Patient-level costs were calculated by applying externally derived US cost weights to resource use counts during trial follow-up. A 3% discount rate was applied to both future costs and benefits. The primary outcome was the incremental cost-effectiveness ratio assessed from the US health care sector perspective. RESULTS: For the CABG arm, we estimated 6.53 quality-adjusted life-years (95% CI, 5.70-7.53) and a lifetime cost of $140 059 (95% CI, $106 401 to $180 992). For the MED arm, the corresponding estimates were 5.52 (95% CI, 5.06-6.09) quality-adjusted life-years and $74 894 lifetime cost (95% CI, $58 372 to $93 541). The incremental cost-effectiveness ratio for CABG compared with MED was $63 989 per quality-adjusted life-year gained. At a societal willingness-to-pay threshold of $100 000 per quality-adjusted life-year gained, CABG was found to be economically favorable compared with MED in 87% of microsimulations. CONCLUSIONS: In the STICH trial, in patients with ischemic cardiomyopathy and reduced left ventricular function, CABG was economically attractive relative to MED at current benchmarks for value in the United States. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifier: NCT00023595.
BACKGROUND: The STICH Randomized Clinical Trial (Surgical Treatment for Ischemic Heart Failure) demonstrated that coronary artery bypass grafting (CABG) reduced all-cause mortality rates out to 10 years compared with medical therapy alone (MED) in patients with ischemic cardiomyopathy and reduced left ventricular function (ejection fraction ≤35%). We examined the economic implications of these results. METHODS: We used a decision-analytic patient-level simulation model to estimate the lifetime costs and benefits of CABG and MED using patient-level resource use and clinical data collected in the STICH trial. Patient-level costs were calculated by applying externally derived US cost weights to resource use counts during trial follow-up. A 3% discount rate was applied to both future costs and benefits. The primary outcome was the incremental cost-effectiveness ratio assessed from the US health care sector perspective. RESULTS: For the CABG arm, we estimated 6.53 quality-adjusted life-years (95% CI, 5.70-7.53) and a lifetime cost of $140 059 (95% CI, $106 401 to $180 992). For the MED arm, the corresponding estimates were 5.52 (95% CI, 5.06-6.09) quality-adjusted life-years and $74 894 lifetime cost (95% CI, $58 372 to $93 541). The incremental cost-effectiveness ratio for CABG compared with MED was $63 989 per quality-adjusted life-year gained. At a societal willingness-to-pay threshold of $100 000 per quality-adjusted life-year gained, CABG was found to be economically favorable compared with MED in 87% of microsimulations. CONCLUSIONS: In the STICH trial, in patients with ischemic cardiomyopathy and reduced left ventricular function, CABG was economically attractive relative to MED at current benchmarks for value in the United States. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifier: NCT00023595.
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