Abstract
Objective: The Cardiothoracic Surgical Trials Network reported that left ventricular reverse remodeling at 2 years did not differ between patients with moderate ischemic mitral regurgitation randomized to coronary artery bypass grafting plus mitral valve repair (n = 150) or coronary artery bypass grafting alone (n = 151). To address health resource use implications, we compared costs and quality-adjusted survival. Methods: We used individual patient data from the Cardiothoracic Surgical Trials Network trial on survival, hospitalizations, quality of life, and US hospitalization costs to estimate cumulative costs and quality-adjusted life years. A microsimulation model was developed to extrapolate to 10 years. Bootstrap and deterministic sensitivity analyses were performed to address uncertainty. Results: In-hospital costs were $59,745 for coronary artery bypass grafting plus mitral valve repair versus $51,326 for coronary artery bypass grafting alone (difference $8419; 95% uncertainty interval, 2259-18,757). Two-year costs were $81,263 versus $67,341 (difference 13,922 [2370 to 28,888]), and quality-adjusted life years were 1.35 versus 1.30 (difference 0.05; −0.04 to 0.14), resulting in an incremental cost-effectiveness ratio of $308,343/quality-adjusted life year for coronary artery bypass grafting plus mitral valve repair. At 10 years, its costs remained higher ($107,733 vs $88,583, difference 19,150 [−3866 to 56,826]) and quality-adjusted life years showed no difference (−0.92 to 0.87), with 5.08 versus 5.08. The likelihood that coronary artery bypass grafting plus mitral valve repair would be considered cost-effective at 10 years based on a cost-effectiveness threshold of $100K/quality-adjusted life year did not exceed 37%. Only when this procedure reduces the death rate by a relative 5% will the incremental cost-effectiveness ratio fall below $100K/quality-adjusted life year. Conclusions: The addition of mitral valve repair to coronary artery bypass grafting for patients with moderate ischemic mitral regurgitation is unlikely to be cost-effective. Only if late mortality benefits can be demonstrated will it meet commonly used cost-effectiveness criteria.
| Original language | English |
|---|---|
| Pages (from-to) | 2230-2240.e15 |
| Journal | Journal of Thoracic and Cardiovascular Surgery |
| Volume | 159 |
| Issue number | 6 |
| DOIs | |
| State | Published - Jun 2020 |
Keywords
- CABG
- Cardiothoracic Surgical Trials Network
- cost-effectiveness analysis
- health care costs
- ischemic mitral regurgitation
- mitral valve
- mitral valve repair
- quality-adjusted life years
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In: Journal of Thoracic and Cardiovascular Surgery, Vol. 159, No. 6, 06.2020, p. 2230-2240.e15.
Research output: Contribution to journal › Article › peer-review
TY - JOUR
T1 - Cost-effectiveness of coronary artery bypass grafting plus mitral valve repair versus coronary artery bypass grafting alone for moderate ischemic mitral regurgitation
AU - Ferket, Bart S.
AU - Thourani, Vinod H.
AU - Voisine, Pierre
AU - Hohmann, Samuel F.
AU - Chang, Helena L.
AU - Smith, Peter K.
AU - Michler, Robert E.
AU - Ailawadi, Gorav
AU - Perrault, Louis P.
AU - Miller, Marissa A.
AU - O'Sullivan, Karen
AU - Mick, Stephanie L.
AU - Bagiella, Emilia
AU - Acker, Michael A.
AU - Moquete, Ellen
AU - Hung, Judy W.
AU - Overbey, Jessica R.
AU - Lala, Anuradha
AU - Iraola, Margaret
AU - Gammie, James S.
AU - Gelijns, Annetine C.
AU - O'Gara, Patrick T.
AU - Moskowitz, Alan J.
AU - Taddei-Peters, Wendy C.
AU - Buxton, Dennis
AU - Caulder, Ron
AU - Geller, Nancy L.
AU - Gordon, David
AU - Jeffries, Neal O.
AU - Lee, Albert
AU - Moy, Claudia S.
AU - Gombos, Ilana Kogan
AU - Ralph, Jennifer
AU - Weisel, Richard
AU - Gardner, Timothy J.
AU - Rose, Eric A.
AU - Parides, Michael K.
AU - Ascheim, Deborah D.
AU - Chang, Helena
AU - Chase, Melissa
AU - Chen, Yingchun
AU - Goldfarb, Seth
AU - Gupta, Lopa
AU - Kirkwood, Katherine
AU - Dobrev, Edlira
AU - Levitan, Ron
AU - Overbey, Jessica
AU - Santos, Milerva
AU - Weglinski, Michael
AU - Williams, Paula
AU - Wood, Carrie
AU - Ye, Xia
AU - Nielsen, Sten Lyager
AU - Wiggers, Henrik
AU - Malgaard, Henning
AU - Mack, Michael
AU - Adame, Tracine
AU - Settele, Natalie
AU - Adams, Jenny
AU - Ryan, William
AU - Smith, Robert L.
AU - Grayburn, Paul
AU - Chen, Frederick Y.
AU - Nohria, Anju
AU - Cohn, Lawrence
AU - Shekar, Prem
AU - Aranki, Sary
AU - Couper, Gregory
AU - Davidson, Michael
AU - Bolman, R. Morton
AU - Burgess, Anne
AU - Conboy, Debra
AU - Noiseux, Nicolas
AU - Stevens, Louis Mathieu
AU - Prieto, Ignacio
AU - Basile, Fadi
AU - Dionne, Joannie
AU - Fecteau, Julie
AU - Blackstone, Eugene H.
AU - Gillinov, A. Marc
AU - Lackner, Pamela
AU - Berroteran, Leoma
AU - Dolney, Diana
AU - Fleming, Suzanne
AU - Palumbo, Roberta
AU - Whitman, Christine
AU - Sankovic, Kathy
AU - Sweeney, Denise Kosty
AU - Pattakos, Gregory
AU - Clarke, Pamela A.
AU - Argenziano, Michael
AU - Williams, Mathew
AU - Goldsmith, Lyn
AU - Smith, Craig R.
AU - Naka, Yoshifumi
AU - Stewart, Allan
AU - Schwartz, Allan
AU - Bell, Daniel
AU - Van Patten, Danielle
AU - Sreekanth, Sowmya
AU - Alexander, John H.
AU - Milano, Carmelo A.
AU - Glower, Donald D.
AU - Mathew, Joseph P.
AU - Harrison, J. Kevin
AU - Welsh, Stacey
AU - Berry, Mark F.
AU - Parsa, Cyrus J.
AU - Tong, Betty C.
AU - Williams, Judson B.
AU - Ferguson, T. Bruce
AU - Kypson, Alan P.
AU - Rodriguez, Evelio
AU - Harris, Malissa
AU - Akers, Brenda
AU - O'Neal, Allison
AU - Puskas, John D.
AU - Guyton, Robert
AU - Baer, Jefferson
AU - Baio, Kim
AU - Neill, Alexis A.
AU - Senechal, Mario
AU - Dagenais, François
AU - O'Connor, Kim
AU - Dussault, Gladys
AU - Ballivian, Tatiana
AU - Keilani, Suzanne
AU - Speir, Alan M.
AU - Magee, Patrick
AU - Ad, Niv
AU - Keyte, Sally
AU - Dang, Minh
AU - Slaughter, Mark
AU - Headlee, Marsha
AU - Moody, Heather
AU - Solankhi, Naresh
AU - Birks, Emma
AU - Groh, Mark A.
AU - Shell, Leslie E.
AU - Shepard, Stephanie A.
AU - Trichon, Benjamin H.
AU - Nanney, Tracy
AU - Hampton, Lynne C.
AU - D'Alessandro, David A.
AU - DeRose, Joseph J.
AU - Goldstein, Daniel J.
AU - Bello, Ricardo
AU - Jakobleff, William
AU - Garcia, Mario
AU - Taub, Cynthia
AU - Spevak, Daniel
AU - Swayze, Roger
AU - Basmadjian, Arsène Joseph
AU - Bouchard, Denis
AU - Carrier, Michel
AU - Cartier, Raymond
AU - Pellerin, Michel
AU - Tanguay, Jean François
AU - El-Hamamsy, Ismail
AU - Denault, André
AU - Demers, Philippe
AU - Robichaud, Sophie
AU - Horvath, Keith A.
AU - Corcoran, Philip C.
AU - Siegenthaler, Michael P.
AU - Murphy, Mandy
AU - Greenberg, Ann
AU - Sai-Sudhakar, Chittoor
AU - Hasan, Ayseha
AU - McDavid, Asia
AU - Kinn, Bradley
AU - Pagé, Pierre
AU - Sirois, Carole
AU - Latter, David
AU - Leong-Poi, Howard
AU - Bonneau, Daniel
AU - Errett, Lee
AU - Peterson, Mark D.
AU - Verma, Subodh
AU - Feder-Elituv, Randi
AU - Cohen, Gideon
AU - Joyner, Campbell
AU - Fremes, Stephen E.
AU - Moussa, Fuad
AU - Christakis, George
AU - Karkhanis, Reena
AU - Yau, Terry
AU - Farkouh, Michael
AU - Woo, Anna
AU - Cusimano, Robert James
AU - David, Tirone
AU - Feindel, Christopher
AU - Garrard, Lisa
AU - Fredericks, Suzanne
AU - Mociornita, Amelia
AU - Mullen, John C.
AU - Choy, Jonathan
AU - Meyer, Steven
AU - Kuurstra, Emily
AU - Young, Cindi A.
AU - Beach, Dana
AU - Atluri, Pavan
AU - Woo, Y. Joseph
AU - Mayer, Mary Lou
AU - Bowdish, Michael
AU - Starnes, Vaughn A.
AU - Shavalle, David
AU - Matthews, Ray
AU - Javadifar, Shadi
AU - Romar, Linda
AU - Kron, Irving L.
AU - Johnston, Karen
AU - Dent, John M.
AU - Kern, John
AU - Keim, Jessica
AU - Burks, Sandra
AU - Gahring, Kim
AU - Bull, David A.
AU - Desvigne-Nickens, Patrice
AU - Dixon, Dennis O.
AU - Haigney, Mark
AU - Holubkov, Richard
AU - Jacobs, Alice
AU - Miller, Frank
AU - Murkin, John M.
AU - Spertus, John
AU - Wechsler, Andrew S.
AU - Sellke, Frank
AU - McDonald, Cheryl L.
AU - Byington, Robert
AU - Dickert, Neal
AU - Ikonomidis, John S.
AU - Williams, David O.
AU - Yancy, Clyde W.
AU - Fang, James C.
AU - Giannetti, Nadia
AU - Richenbacher, Wayne
AU - Rao, Vivek
AU - Furie, Karen L.
AU - Miller, Rachel
AU - Pinney, Sean
AU - Roberts, William C.
AU - Walsh, Mary N.
AU - Keteyian, Stephen J.
AU - Brawner, Clinton A.
AU - Aldred, Heather
AU - Hung, Judy
AU - Zeng, Xin
AU - Browndyke, Jeffrey
AU - Toulgoat-Dubois, Yanne
N1 - Funding Information: The CTSN moderate ischemic MR trial 6,7 was funded by the National Institutes of Health and the Canadian Institutes of Health Research and conducted at 26 clinical centers. A total of 301 patients with multivessel coronary artery disease and moderate ischemic MR were randomized between 2009 and 2013 to undergo CABG alone (n = 151) or CABG plus MV repair (n = 150). CABG was performed on-pump using standard techniques, and all patients received guideline-directed medical therapy. In patients randomized to CABG plus MV repair, a rigid or semi-rigid complete annuloplasty ring was used. The ring was downsized by 2 sizes when possible to correct for annular dilatation. The specific ring type, implantation technique, and myocardial preservation method were at the surgeon's discretion. Causes of death and adverse events were adjudicated by an independent committee of experts. A National Institutes of Health–appointed data and safety monitoring board oversaw trial progress. Funding Information: This work was supported by a cooperative agreement (U01 HL088942) funded by the National Heart, Lung, and Blood Institute and the National Institute of Neurological Disorders and Stroke of the National Institutes of Health and the Canadian Institutes of Health Research. B.S.F. was supported by American Heart Association Grant #16MCPRP31030016 (to Dr Ferket). The views expressed in this article are those of the authors and do not necessarily represent the views of the National Heart, Lung, and Blood Institute; National Institutes of Health; or the US Department of Health and Human Services. Publisher Copyright: © 2019 The American Association for Thoracic Surgery
PY - 2020/6
Y1 - 2020/6
N2 - Objective: The Cardiothoracic Surgical Trials Network reported that left ventricular reverse remodeling at 2 years did not differ between patients with moderate ischemic mitral regurgitation randomized to coronary artery bypass grafting plus mitral valve repair (n = 150) or coronary artery bypass grafting alone (n = 151). To address health resource use implications, we compared costs and quality-adjusted survival. Methods: We used individual patient data from the Cardiothoracic Surgical Trials Network trial on survival, hospitalizations, quality of life, and US hospitalization costs to estimate cumulative costs and quality-adjusted life years. A microsimulation model was developed to extrapolate to 10 years. Bootstrap and deterministic sensitivity analyses were performed to address uncertainty. Results: In-hospital costs were $59,745 for coronary artery bypass grafting plus mitral valve repair versus $51,326 for coronary artery bypass grafting alone (difference $8419; 95% uncertainty interval, 2259-18,757). Two-year costs were $81,263 versus $67,341 (difference 13,922 [2370 to 28,888]), and quality-adjusted life years were 1.35 versus 1.30 (difference 0.05; −0.04 to 0.14), resulting in an incremental cost-effectiveness ratio of $308,343/quality-adjusted life year for coronary artery bypass grafting plus mitral valve repair. At 10 years, its costs remained higher ($107,733 vs $88,583, difference 19,150 [−3866 to 56,826]) and quality-adjusted life years showed no difference (−0.92 to 0.87), with 5.08 versus 5.08. The likelihood that coronary artery bypass grafting plus mitral valve repair would be considered cost-effective at 10 years based on a cost-effectiveness threshold of $100K/quality-adjusted life year did not exceed 37%. Only when this procedure reduces the death rate by a relative 5% will the incremental cost-effectiveness ratio fall below $100K/quality-adjusted life year. Conclusions: The addition of mitral valve repair to coronary artery bypass grafting for patients with moderate ischemic mitral regurgitation is unlikely to be cost-effective. Only if late mortality benefits can be demonstrated will it meet commonly used cost-effectiveness criteria.
AB - Objective: The Cardiothoracic Surgical Trials Network reported that left ventricular reverse remodeling at 2 years did not differ between patients with moderate ischemic mitral regurgitation randomized to coronary artery bypass grafting plus mitral valve repair (n = 150) or coronary artery bypass grafting alone (n = 151). To address health resource use implications, we compared costs and quality-adjusted survival. Methods: We used individual patient data from the Cardiothoracic Surgical Trials Network trial on survival, hospitalizations, quality of life, and US hospitalization costs to estimate cumulative costs and quality-adjusted life years. A microsimulation model was developed to extrapolate to 10 years. Bootstrap and deterministic sensitivity analyses were performed to address uncertainty. Results: In-hospital costs were $59,745 for coronary artery bypass grafting plus mitral valve repair versus $51,326 for coronary artery bypass grafting alone (difference $8419; 95% uncertainty interval, 2259-18,757). Two-year costs were $81,263 versus $67,341 (difference 13,922 [2370 to 28,888]), and quality-adjusted life years were 1.35 versus 1.30 (difference 0.05; −0.04 to 0.14), resulting in an incremental cost-effectiveness ratio of $308,343/quality-adjusted life year for coronary artery bypass grafting plus mitral valve repair. At 10 years, its costs remained higher ($107,733 vs $88,583, difference 19,150 [−3866 to 56,826]) and quality-adjusted life years showed no difference (−0.92 to 0.87), with 5.08 versus 5.08. The likelihood that coronary artery bypass grafting plus mitral valve repair would be considered cost-effective at 10 years based on a cost-effectiveness threshold of $100K/quality-adjusted life year did not exceed 37%. Only when this procedure reduces the death rate by a relative 5% will the incremental cost-effectiveness ratio fall below $100K/quality-adjusted life year. Conclusions: The addition of mitral valve repair to coronary artery bypass grafting for patients with moderate ischemic mitral regurgitation is unlikely to be cost-effective. Only if late mortality benefits can be demonstrated will it meet commonly used cost-effectiveness criteria.
KW - CABG
KW - Cardiothoracic Surgical Trials Network
KW - cost-effectiveness analysis
KW - health care costs
KW - ischemic mitral regurgitation
KW - mitral valve
KW - mitral valve repair
KW - quality-adjusted life years
UR - http://www.scopus.com/inward/record.url?scp=85069878953&partnerID=8YFLogxK
U2 - 10.1016/j.jtcvs.2019.06.040
DO - 10.1016/j.jtcvs.2019.06.040
M3 - Article
C2 - 31375378
AN - SCOPUS:85069878953
SN - 0022-5223
VL - 159
SP - 2230-2240.e15
JO - Journal of Thoracic and Cardiovascular Surgery
JF - Journal of Thoracic and Cardiovascular Surgery
IS - 6
ER -