Cost effectiveness of clinically appropriate decisions on alternative treatments for angina pectoris: prospective observational study
Cost effectiveness of clinically appropriate decisions on alternative treatments for angina pectoris: prospective observational study
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DOI：
10.1136/bmj.39129.442164.55
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发表时间：
2007-03-24
影响因子：
105.7
通讯作者：
Hemingway, H.
中科院分区：
文献类型：
--
作者：
Griffin, S. C.;Barber, J. A.;Hemingway, H.
目的 评估被认为临床上合适的血运重建术是否也具有成本效益。设计前瞻性观察性研究，比较冠状动脉旁路移植术、经皮冠状动脉介入治疗或被评定为适合血运重建的患者组内的医疗管理的成本效益。设置伦敦的三个三级护理中心。参与者连续、未经选择的被评定为临床上合适的患者（使用九名德尔菲小组）仅接受冠状动脉旁路移植术（n=815）；仅经皮冠状动脉介入治疗（n=385）；或两种血运重建手术 (n=520)。 主要结果指标 六年随访期间获得的每个质量调整生命年的成本，以国家卫生服务成本角度计算，并按 3.5%/年折扣。 结果 与仅适合冠状动脉旁路移植的患者相比，与经皮冠状动脉介入治疗相比，冠状动脉旁路移植术获得的每个质量调整生命年成本为 22 磅 000 (E33 000; 43 000 美元)（59% 的可能性是与适用于两种类型血运重建的医疗管理相比，成本效益阈值为每个质量调整生命年 30 英镑 000 英镑）和每个质量调整生命年 19 英镑 000 英镑（成本效益概率为 63%）。在每个质量调整生命年 30 英镑的阈值下，三个适当性组中没有一个经皮冠状动脉介入治疗具有成本效益。在仅适合接受经皮冠状动脉介入治疗的患者中，与药物治疗相比，经皮冠状动脉介入治疗获得的每个质量调整生命年的成本为 47 英镑，超过了通常的成本效益阈值；在这些患者中，医疗管理最有可能具有成本效益（概率为 54%）。 结论 在临床上判断适合冠状动脉血运重建的患者中，冠状动脉旁路移植术似乎具有成本效益，但经皮冠状动脉介入治疗则不然。基于观察数据的成本效益分析表明，经皮冠状动脉介入治疗的临床益处可能不足以证明其成本的合理性。
Objective To assess whether revascularisation that is considered to be clinically appropriate is also cost effective.Design Prospective observational study comparing cost effectiveness of coronary artery bypass grafting, percutaneous coronary intervention, or medical management within groups of patients rated as appropriate for revascularisation.Setting Three tertiary care centres in London.Participants Consecutive, unselected patients rated as clinically appropriate (using a nine member Delphi panel) to receive coronary artery bypass grafting only (n=815); percutaneous coronary intervention only (n=385); or both revascularisation procedures (n=520).Main outcome measure Cost per quality adjusted life year gained over six year follow-up, calculated with a National Health Service cost perspective and discounted at 3.5%/year.Results Coronary artery bypass grafting cost 22 pound 000 (E33 000; $43 000) per quality adjusted life year gained compared with percutaneous coronary intervention among patients appropriate for coronary artery bypass grafting only (59% probability of being cost effective at a cost effectiveness threshold of 30 pound 000 per quality adjusted life year) and 19 pound 000 per quality adjusted life year gained compared with medical management among those appropriate for both types of revascularisation (probability of being cost effective 63%). In none of the three appropriateness groups was percutaneous coronary intervention cost effective at a threshold of 30 pound 000 per quality adjusted life year. Among patients rated appropriate for percutaneous coronary intervention only, the cost per quality adjusted life year gained for percutaneous coronary intervention compared with medical management was 47 pound 000, exceeding usual cost effectiveness thresholds; in these patients, medical management was most likely to be cost effective (probability 54%).Conclusions Among patients judged clinically appropriate for coronary revascularisation, coronary artery bypass grafting seemed cost effective but percutaneous coronary intervention did not. Cost effectiveness analysis based on observational data suggests that the clinical benefit of percutaneous coronary intervention may not be sufficient to justify its cost.