Original Investigation
Cost-Effectiveness of Revascularization Strategies: The ASCERT Study

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Abstract

Background

ASCERT (American College of Cardiology Foundation and the Society of Thoracic Surgeons Collaboration on the Comparative Effectiveness of Revascularization Strategies) was a large observational study designed to compare the long-term effectiveness of coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI) to treat coronary artery disease (CAD) over 4 to 5 years.

Objectives

This study examined the cost-effectiveness of CABG versus PCI for stable ischemic heart disease.

Methods

The Society of Thoracic Surgeons and American College of Cardiology Foundation databases were linked to the Centers for Medicare and Medicaid Services claims data. Costs for the index and observation period (2004 to 2008) hospitalizations were assessed by diagnosis-related group Medicare reimbursement rates; costs beyond the observation period were estimated from average Medicare participant per capita expenditure. Effectiveness was measured via mortality and life-expectancy data. Cost and effectiveness comparisons were adjusted using propensity score matching with the incremental cost-effectiveness ratio expressed as cost per quality-adjusted life-year gained.

Results

CABG patients (n = 86,244) and PCI patients (n = 103,549) were at least 65 years old with 2- or 3-vessel coronary artery disease. Adjusted costs were higher for CABG for the index hospitalization, study period, and lifetime by $10,670, $8,145, and $11,575, respectively. Patients undergoing CABG gained an adjusted average of 0.2525 and 0.3801 life-years relative to PCI over the observation period and lifetime, respectively. The life-time incremental cost-effectiveness ratio of CABG compared to PCI was $30,454/QALY gained.

Conclusions

Over a period of 4 years or longer, patients undergoing CABG had better outcomes but at higher costs than those undergoing PCI.

Key Words

coronary artery bypass graft
incremental cost-effectiveness ratio
percutaneous coronary intervention
stable ischemic heart disease

Abbreviations and Acronyms

ACCF
American College of Cardiology Foundation
CABG
coronary artery bypass graft
CAD
coronary artery disease
CI
confidence interval
DES
drug-eluting stent(s)
DRG
diagnosis-related group
ICER
incremental cost-effectiveness ratio
IPW
inverse probability-weighting
LYG
life-years gained
MI
myocardial infarction
PCI
percutaneous coronary intervention
PSBB
propensity score bin bootstrapping
QALY
quality-adjusted life-year
STS
Society of Thoracic Surgeons

Cited by (0)

This work is supported by a grant from the National Heart, Lung, and Blood Institute (#RC2HL101489) and by an Institutional Development Award from the National Institute of General Medical Sciences (#U54-GM104941) of the National Institutes of Health. Dr. Grover consults for, but does not receive fees from, Somalution. Dr. Garratt consults for The Medicines Company and Boston Scientific Corporation; and receives research support from Boston Scientific Corporation, DSI/Lily, CeloNova, and the Mayo Foundation. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Steven Nissen, MD, served as Guest Editor for this paper.

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