Current issues of ACP Journal Club are published in Annals of Internal Medicine


Economics

The 5-year cost of coronary angioplasty was lower than that of bypass surgery only in patients with 2-vessel coronary disease

ACP J Club. 1997 Jul-Aug;127:25. doi:10.7326/ACPJC-1997-127-1-025


Source Citation

Hlatky MA, Rogers WJ, Johnstone I, et al., for the Bypass Angioplasty Revascularization Investigation (BARI) Investigators. Medical care costs and quality of life after randomization to coronary angioplasty or coronary bypass surgery. N Engl J Med. 1997 Jan 9;336:92-9.


Abstract

Objective

To compare the quality of life and costs among patients receiving percutaneous transluminal coronary angioplasty (PTCA) with patients receiving coronary artery bypass grafting (CABG).

Design

Randomized controlled trial with a mean follow-up of 5.5 years.

Setting

7 clinical sites in the United States.

Patients

934 patients (mean age 62 y, 72% men) who had angina or objective evidence of myocardial ischemia severe enough to warrant coronary revascularization, stenosis of ≥ 50% in ≥ 2 primary coronary vessels, technical suitability for both PTCA or CABG, and no previous coronary revascularization procedure.

Intervention

465 patients were allocated to PTCA and 469 to CABG.

Main cost and outcome measures

Data on functional status and emotional health were collected annually, and employment status and economic data (costs of medical services and cardiac medications) were collected quarterly. Costs were reported in 1995 U.S. dollars.

Main results

Patients assigned to CABG had greater improvement in functional status at 1 year, 2 years, and 3 years (P ≤ 0.04) than did those assigned to PTCA. After 4 and 5 years, however, the groups did not differ. Emotional health improved in both groups, but the changes from baseline did not differ between groups. Patients assigned to PTCA returned to work 5 weeks sooner than did patients assigned to CABG (P < 0.001), but the proportion of patients who returned to work did not differ. The initial mean cost of PTCA was 65% that of CABG ($21 113 vs $32 347, P < 0.001). After 5 years, however, the total medical cost of PTCA was 95% that of CABG ($56 225 vs $58 889, P = 0.047). The 5-year cost of PTCA was lower than that of CABG among patients with 2-vessel disease ($52 930 vs $58 498, P < 0.05) but not among patients with 3-vessel disease ($60 918 vs $59 430). After 5 years of follow-up, CABG had a cost-effectiveness ratio of $60 057/y of life added for patients with 2-vessel disease and a trend toward lower cost and better survival for patients with 3-vessel disease or diabetes.

Conclusions

Coronary artery bypass grafting led to improved quality of life for the first 3 years after the procedure in patients with multivessel coronary disease. The 5-year cost of percutaneous transluminal coronary angioplasty was lower than that of bypass surgery only in patients with 2-vessel coronary disease.

Sources of funding: Robert Wood Johnson Foundation and National Heart, Lung, and Blood Institute.

For article reprint: Dr. M.A. Hlatky, Stanford University School of Medicine, HRP Redwood Building, Room 150, Stanford, CA 94305-5092, USA. FAX 415-723-3786.


Commentary

Patients who have multivessel coronary artery disease now have a wealth of information on the outcomes of treatment. The study by Hlatky and colleagues provides an excellent discussion of the costs and outcomes of 2 interventions, PTCA and CABG. These data were developed from a substudy of the Bypass Angioplasty Revascularization Investigation (BARI) study. The study showed that patients who have PTCA have lower initial treatment costs and return to work faster than do patients who have CABG. However, during 5 years of follow-up, the initial advantages diminish for patients with 2-vessel disease and are nonexistent for patients with 3-vessel disease or diabetes. In fact, the BARI study showed that patients with diabetes had a survival advantage with CABG.

Discussion of the survival results of the BARI study has appeared elsewhere (1). The study by Hlatky and colleagues provides more extensive information than earlier studies on the quality of life and costs of these 2 treatment strategies.

Based on this study, can recommendations about revascularization be made for patients with multivessel disease? Unfortunately, the answer is no. One limitation of technology assessment is the speed at which technology advances. Definitive answers to the questions of the 1980s must now be assessed in the context of new technologies that may offer the potential for clinical improvement in patients: stents, agents that reduce thrombosis during PTCA, minimally invasive CABG procedures, and intensive secondary prevention through treatment of high blood cholesterol levels.

How does one evaluate the BARI study in light of these potential new technologies? The investigation has provided strong evidence that early benefits of PTCA were not sustained over time for subgroups of patients. Despite the promise of new technologies, we should be cautious about recommending new revascularization strategies until substantial evidence has been accumulated to support their use.

Kevin A. Schulman, MD
Georgetown University Medical CenterWashington, DC, USA

Kevin A. Schulman, MD
Georgetown University Medical Center
Washington, DC, USA


Reference

1. Simoons ML. Myocardial revascularization-bypass surgery or angioplasty. N Engl J Med. 1996;335:275-6.