Economic evaluation of complete revascularization for patients with multivessel disease undergoing primary percutaneous coronary intervention

Objective: To determine the cost-effectiveness of complete revascularisation at index admission compared to infarct-related artery (IRA) treatment only, in patients with multi-vessel disease undergoing Primary percutaneous coronary intervention (P-PCI) for ST-segment elevation Myocardial Infarction (STEMI). Methods: Economic evaluation of a multi-centre randomised trial comparing complete revascularisation at index admission to IRA-only P-PCI in patients with multi-vessel disease (12 month follow-up). Overall hospital costs (costs for P-PCI procedure(s), hospital stay and any subsequent readmissions) were estimated. Outcomes were major adverse cardiac events (MACE, a composite of all-cause death, recurrent myocardial infarction, heart failure, and ischemia-driven revascularisation) and quality-adjusted life years (QALYs) derived from the EQ-5D-3L. Multiple imputation was undertaken. The mean incremental cost and effects, with associated 95% confidence intervals (95%CI), the incremental cost-effectiveness ratio (ICER) and the cost-effectiveness acceptability curve (CEAC) were estimated. Results: Based on 296 patients, the mean incremental overall hospital cost for complete revascularisation was estimated to be –£215.96 (–£1,390.20 to £958.29), compared to IRA-only, with a per-patient mean reduction in MACE events of 0.170 (0.044 to 0.296) and a QALY gain of 0.011 (-0.019 to 0.041). According to the CEAC, the probability of complete revascularisation being cost-effective was estimated to be 72.0% at willingness to pay of £20,000 per QALY. Conclusions: Complete revascularisation at index admission was estimated to be more effective (in terms of MACE and QALYs) and cost-effective (overall costs were estimated to be lower and complete revascularisation thereby dominated IRA-only). There was, however, some uncertainty associated with this decision.