Siebert U, Cohen DJ, Kuntz KK; International Society of Technology Assessment in Health Care. Meeting.

Annu Meet Int Soc Technol Assess Health Care Int Soc Technol Assess Health Care Meet. 2002; 18: abstract no. 284.

Harvard School of Public Health, 718 Huntington Avenue, Boston, MA, usiebert@hsph.harvard.edu; kmk@hsph.harvard.edu

BACKGROUND/OBJECTIVES: Although many patients with coronary stenosis undergo percutaneous transluminal coronary angioplasty (PTCA) in the absence of prior documented ischemia, the effectiveness of this strategy is unknown. Coronary pressure-based fractional flow reserve (FFR) is an accurate invasive test for myocardial ischemia. Coronary pressure wires have evolved from investigational devices to simple and often indispensable diagnostic tools. The objective of this study was to assess the clinical effectiveness and the cost-effectiveness of deferral vs. performance of PTCA in patients with chest pain. METHODS: Outcomes for patients with one-vessel coronary stenosis and mild angina but without documented ischemia were simulated in a Markov model. The compared strategies were (1) deferral of PTCA in patients with no inducible ischemia based on FFR (DEFER) and (2) performance of PTCA without FFR testing (PERFORM). Clinical predictions and a cost-effectiveness analysis were performed in age (30-70 years) and gender subgroups. One-way and multi-way sensitivity analyses were conducted on uncertain model parameters. RESULTS: Overall, men and women had similar patterns, showing DEFER as the less costly but slightly less effective strategy. For the base case (60 year old man, 3% discount rate) we calculated the following results (PERFORM vs. DEFER): incremental costs $4,400; incremental life expectancy 10.9 days; 17.5 incremental QALDs. Costs were $145,000 per life year gained and $90,000 per QALY for PERFORM compared to DEFER. In sensitivity analyses we changed the mortality reduction associated with PTCA in patients with no ischemia from the base-case value of 8.2% to 0%. For a 60-year-old man, this reduced the incremental effectiveness to 4.5 quality-adjusted life days (QALDs), increased the cost-effectiveness ratio to $354,000/QALY and made DEFER the dominant strategy using survival as outcome (DEFER saved 4.8 life days and $4,300). Changing prior probability of ischemia from 56% to 92% decreased the cost-effectiveness ratio of PERFORM below the widely accepted threshold of $50,000/QALY. DISCUSSION: Although pressure-based deferral of angioplasty is less costly in patients without documented ischemia, its long-term effectiveness remains unclear. However, as differences in effectiveness are likely to be small, deferral of PTCA may be considered in patients without functional stenosis assessed by coronary pressure measurement if health care resources are constrained.

Publication Types:

• Meeting Abstracts

Keywords:

• Angina Pectoris
• Angioplasty, Transluminal, Percutaneous Coronary
• Chest Pain
• Coronary Stenosis
• Cost-Benefit Analysis
• Costs and Cost Analysis
• Female
• Heart Catheterization
• Heart Function Tests
• Humans
• Male
• Pressure
• Quality-Adjusted Life Years
• Sensitivity and Specificity
• economics
• surgery
• hsrmtgs

Other ID:

• GWHSR0003221

UI: 102274900

From Meeting Abstracts