Treatment for stable coronary artery disease: a network meta-analysis of cost-effectiveness studies

Thibaut Caruba, Sandrine Katsahian, Catherine Schramm, Anaïs Charles Nelson, Pierre Durieux, Dominique Bégué, Yves Juillière, Olivier Dubourg, Nicolas Danchin, Brigitte Sabatier, Thibaut Caruba, Sandrine Katsahian, Catherine Schramm, Anaïs Charles Nelson, Pierre Durieux, Dominique Bégué, Yves Juillière, Olivier Dubourg, Nicolas Danchin, Brigitte Sabatier

Abstract

Introduction and objectives: Numerous studies have assessed cost-effectiveness of different treatment modalities for stable angina. Direct comparisons, however, are uncommon. We therefore set out to compare the efficacy and mean cost per patient after 1 and 3 years of follow-up, of the following treatments as assessed in randomized controlled trials (RCT): medical therapy (MT), percutaneous coronary intervention (PCI) without stent (PTCA), with bare-metal stent (BMS), with drug-eluting stent (DES), and elective coronary artery bypass graft (CABG).

Methods: RCT comparing at least two of the five treatments and reporting clinical and cost data were identified by a systematic search. Clinical end-points were mortality and myocardial infarction (MI). The costs described in the different trials were standardized and expressed in US $ 2008, based on purchasing power parity. A network meta-analysis was used to compare costs.

Results: Fifteen RCT were selected. Mortality and MI rates were similar in the five treatment groups both for 1-year and 3-year follow-up. Weighted cost per patient however differed markedly for the five treatment modalities, at both one year and three years (P<0.0001). MT was the least expensive treatment modality: US $3069 and 13 864 after one and three years of follow-up, while CABG was the most costly: US $27 003 and 28 670 after one and three years. PCI, whether with plain balloon, BMS or DES came in between, but was closer to the costs of CABG.

Conclusions: Appreciable savings in health expenditures can be achieved by using MT in the management of patients with stable angina.

Conflict of interest statement

Competing Interests: The authors have read the journal's policy. Three co-authors have the following conflicts: 1) Pr Dubourg: consultancy: Bracco Altam Pharma; and grant: Sorin France and Medtronic. 2) Pr Juillière: consultancy: Abbott vascular, AstraZeneca, Bayer, Bristol-Myers-Squibb, MSD-Schering, Novartis, Sanofi Aventis and Servier; and grant: AstraZeneca. 3) Pr Danchin: board membership: AstraZeneca, Bayer, Daiichi-Sankyo, Eli-Lilly, Novo-nordisk and Servier; consultancy: GSK and Sanofi Aventis; and grant: MSD, AstraZeneca, Daiichi-Sankyo, Eli-Lilly, GSK, Novartis and Sanofi Aventis. This does not alter the authors' adherence to PLOS ONE policies on sharing data and materials.

Figures

Figure 1. Flow diagram of the screening…
Figure 1. Flow diagram of the screening process.
Figure 2. Comparators and duration of patient…
Figure 2. Comparators and duration of patient follow-up for the trials selected.
Figure 3. Cumulative incidences of death and…
Figure 3. Cumulative incidences of death and MI.
Figure 4. Cost per patient adjusted in…
Figure 4. Cost per patient adjusted in US $ 2008 after 1 and 3 years of follow-up (each mark represents a clinical study).
Figure 5. Mean weighted cost per patient…
Figure 5. Mean weighted cost per patient in US $ 2008 and standard deviation (number of RCT available).

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