Bypass Surgery More Cost Effective Than Coronary Angioplasty

Bypass surgery offers better outcomes at a lower cost than angioplasty with stenting for patients with multivessel coronary artery disease, according to a report in the October 1st issue of The American Journal of Medicine.

Recent reports have reported similar survival rates after coronary artery bypass graft (CABG) surgery and after stenting, the authors explain, but the cost effectiveness of the two treatments has not been compared since coronary stenting became a prevalent adjunct to angioplasty.

Dr. Mark A. Hlatky from Stanford University School of Medicine, Stanford, California and colleagues used computer models and data from the Study of Economics and Quality of Life substudy of the Bypass Angioplasty Revascularization Investigation to compare the lifetime cost-effectiveness of CABG and coronary angioplasty with stenting.

Overall survival was 0.84 years longer after CABG than after stenting, the authors report, and CABG offered better quality-adjusted life year (QALY) outcomes than did stenting.

CABG as initial treatment was less expensive and more effective than initial angioplasty with stenting under all strategies examined by the model, the report indicates, and the superiority of CABG held up over a wide range of variable estimates in extensive sensitivity analyses.

“Stents improve the safety and efficiency of balloon angioplasty because they reduce the need for emergency CABG and staged procedures,” the investigators conclude. “Our results suggest that although elimination of target lesion restenosis does improve the short-term outcomes of catheter-based interventions, these improvements are not enough to make primary stenting less costly and more effective than CABG for relieving angina in patients with multivessel disease.”

“Some patients may wish to avoid surgery, either because of the major trauma or the risk of cognitive dysfunction,” Dr. Hlatky told Reuters Health. “These individuals should certainly have percutaneous coronary intervention, as there is a much lower likelihood they will need surgery. In general the outcomes are close enough that patient preferences should affect the choice. Also the preference for CABG is most clear in 3-vessel disease, and it’s closer in 2-vessel disease.”

“Our study was a simulation, not a clinical trial,” Dr. Hlatky cautioned. “Clinical decisions should be based on the evidence and also on the patient’s preferences and local expertise with the alternatives, since this is a relatively ‘close call.'”

“Decision analytic modeling is a vital tool for synthesizing multiple sources of evidence-some from randomized trials, and some from clinical series on benefits, risks, and costs that may reflect more recent experience than that available from randomized trials,” writes Dr. Milton C. Weinstein from Harvard School of Public Health, Boston, Massachusetts in a related editorial. “Well-calibrated decision models that ‘update’ well-conducted clinical trials to reflect contemporary technologies and costs can play a useful role in informing clinical and policy decisions and are consistent with the principles of evidence-based medicine.”

Am J Med 2003;115:382-389,410-411.