Intended for healthcare professionals

News Roundup [abridged Versions Appear In The Paper Journal]

Angioplasty is cheaper than surgery and is just as effective

BMJ 2006; 333 doi: https://doi.org/10.1136/bmj.333.7570.672 (Published 28 September 2006) Cite this as: BMJ 2006;333:672
  1. Susan Mayor
  1. London

    Percutaneous coronary intervention, also known as angioplasty, is as effective as coronary artery bypass grafting in treating patients with refractory angina who are at high risk of adverse outcomes, a new US study has concluded. It found that over five years angioplasty is nearly 20% cheaper.

    An earlier study had randomised high risk patients with medically refractory myocardial ischaemia—a group of patients who have largely been excluded from previous trials—to urgent revascularisation with either angioplasty or coronary artery bypass grafting.

    Results for the 454 patients, who were recruited from 16 medical centres of the US Department of Veterans Affairs, showed that survival at three years was 0.82 for patients who had angioplasty and 0.79 for those who had grafting (P for difference 0.34). Survival remained similar for both procedures at five years: 0.75 for angioplasty and 0.7 for grafting (P=0.21).

    New results from a cost analysis of data concerning 445 of the patients originally randomised showed that the average total healthcare cost after three years was $63 896 (£33 700; €50 300) for angioplasty and $84 364 for grafting, a saving of $20 468 (95% confidence interval $13 918 to $27 569) (Circulation 2006;114:1251-7). This study, by Kevin Stroupe, a health economist at the Edward Hines Jr Veterans Affairs Hospital, Hines, Illinois, and colleagues used “bootstrapping” to assess the precision of the cost effectiveness estimate, a method of estimating costs that takes a range of inter-related variables into account. Angioplasty was shown to be less costly and more effective at three years in 93% of the bootstrap replications.

    After five years the average total cost was $81 790 for angioplasty and $100 522 for grafting, a difference of $18 732 ($9873 to $27 831). At five years angioplasty remained less costly and more effective in 89% of the bootstrap replications.

    The authors concluded: “PCI [percutaneous coronary intervention] was less costly and at least as effective for the urgent revascularisation of medically refractory, high risk patients over five years.”

    They said that survival was at least as good with angioplasty, indicating that it is the economically “dominant” strategy for high risk patients. The study was carried out before drug eluting stents were available; but although adding their costs to the total costs of angioplasty might reduce the difference in cost between angioplasty and grafting, the authors considered that it would not erase the saving completely.

    In an accompanying editorial Martha Radford, of the New York University School of Medicine, said the researchers “have demonstrated in their elegant cost—effectiveness analysis … that the costs of the surgical strategy are higher than the costs of the percutaneous strategy and that the outcomes are no different.” She said that the study's findings may change decisions about the use of the two procedures.

    Coronary artery bypass grafting has traditionally been considered better for the type of high risk patients included in the study. But Dr Radford said that these new results on comparative costs “raise the question of which patients with coronary artery disease benefit from CABG [coronary artery bypass grafting] more than any other therapy.”

    “It is conceivable that this group is now small indeed,” she said.