Cost-effectiveness of percutaneous coronary intervention versus bypass surgery from a Dutch perspective

Heart. 2015 Dec;101(24):1980-8. doi: 10.1136/heartjnl-2015-307578. Epub 2015 Nov 9.


Aims: Recent cost-effectiveness analyses of percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) have been limited by a short time horizon or were restricted to the US healthcare perspective. We, therefore, used individual patient-level data from the SYNTAX trial to evaluate the cost-effectiveness of PCI versus CABG from a European (Dutch) perspective.

Methods and results: Between 2005 and 2007, 1800 patients with three-vessel or left main coronary artery disease were randomised to either CABG (n=897) or PCI with drug-eluting stents (DES; n=903). Costs were estimated for all patients based on observed healthcare resource usage over 5 years of follow-up. Health state utilities were evaluated with the EuroQOL questionnaire. A patient-level microsimulation model based on Dutch life-tables was used to extrapolate the 5-year in-trial data to a lifetime horizon. Although initial procedural costs were lower for CABG, total initial hospitalisation costs per patient were higher (€17 506 vs €14 037, p<0.001). PCI was more costly during the next 5 years of follow-up, due to more frequent hospitalisations, repeat revascularisation procedures and higher medication costs. Nevertheless, total 5-year costs remained €2465/patient higher with CABG. When the in-trial results were extrapolated to a lifetime horizon, CABG was projected to be economically attractive relative to DES-PCI, with gains in both life expectancy and quality-adjusted life expectancy. The incremental cost-effectiveness ratio (ICER) (€5390/quality-adjusted life year (QALY) gained) was favourable and remained <€80 000/QALY in >90% of the bootstrap replicates. Outcomes were similar when incorporating the prognostic impact of non-fatal myocardial infarction and stroke, as well as across a broad range of assumptions regarding the effect of CABG on post-trial survival and costs. However, DES-PCI was economically dominant compared with CABG in patients with a SYNTAX Score ≤22 or in those with left main disease. In patients for whom the SYNTAX Score II favoured PCI based on lower predicted 4-year mortality, PCI was also economically dominant, whereas in those patients for whom the SYNTAX Score II favoured surgery, CABG was highly economically attractive (ICER range, €2967 to €3737/QALY gained).

Conclusions: For the broad population with three-vessel or left main disease who are candidates for either CABG or PCI, we found that CABG is a clinically and economically attractive revascularisation strategy compared with DES-PCI from a Dutch healthcare perspective. The cost-effectiveness of CABG versus PCI differed according to several anatomic factors, however. The newly developed SYNTAX Score II provides enhanced prognostic discrimination in this population, and may be a useful tool to guide resource allocation as well.

Trial registration number: Clinical trial unique identifier: NCT00114972 (

Publication types

  • Comparative Study
  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Computer Simulation
  • Coronary Artery Bypass / adverse effects
  • Coronary Artery Bypass / economics*
  • Coronary Artery Bypass / mortality
  • Coronary Artery Disease / diagnosis
  • Coronary Artery Disease / economics*
  • Coronary Artery Disease / mortality
  • Coronary Artery Disease / therapy*
  • Cost-Benefit Analysis
  • Decision Support Techniques
  • Drug-Eluting Stents / economics
  • Health Status
  • Hospital Costs*
  • Humans
  • Length of Stay / economics
  • Models, Economic
  • Netherlands
  • Patient Readmission / economics
  • Patient Selection
  • Percutaneous Coronary Intervention / adverse effects
  • Percutaneous Coronary Intervention / economics*
  • Percutaneous Coronary Intervention / instrumentation
  • Percutaneous Coronary Intervention / mortality
  • Quality of Life
  • Quality-Adjusted Life Years
  • Retreatment / economics
  • Surveys and Questionnaires
  • Time Factors
  • Treatment Outcome

Associated data