Chapter 72: Cost-Effectiveness in Interventional Cardiology

INTRODUCTION

The management of cardiovascular diseases, especially coronary artery disease, has been revolutionized after Dr. Mason Sones performed the first coronary angiography in 1960 and Dr. Andreas Gruentzig pioneered percutaneous coronary intervention in 1977. Since 1977, percutaneous techniques for coronary angioplasty have significantly evolved. Interventional cardiology has emerged as a subspecialty of cardiology with tremendous potential of impacting patient outcomes in a broad spectrum of cardiovascular diseases including, but not limited to, acute coronary syndromes, stable coronary artery disease, heart failure syndromes, and valvular heart diseases. From the development of ever-improving coronary interventional equipements and techniques to facilitate treatment of the most complex coronary disease to the introduction of catheter-based therapy for nonoperable aortic stenosis, interventional cardiology has seen a major transformation in therapeutic possibilities over the last decade, and the continuously expanding horizon of interventional cardiology well demonstrates its potential beyond just coronary intervention as first witnessed in 1977. Nonetheless, selecting a specific therapy and offering it to the right patient become challenging in our society of limited resources. Careful evaluation of available evidence becomes vital in determining the appropriateness of a specific intervention, considering both clinical efficacy and cost-effectiveness. Cost-effectiveness of the most significant therapeutic developments in interventional cardiology over the last 2 decades is reviewed in this chapter. A basic approach in cost-effectiveness analysis is briefly reviewed here.

BASIC APPROACHES AND METHODS OF COST-EFFECTIVENESS ANALYSIS

Incremental Cost-Effectiveness Ratio (ICER)

ICER is a widely utilized and accepted standard to evaluate cost-effectiveness of a particular intervention, and the majority of the studies that are discussed in this chapter have used an ICER as the fundamental metric. The ICER is defined as the incremental cost of providing a specific intervention or therapy divided by the incremental gain in the health benefit.¹ Thus, any new intervention will be compared to a previous type of care, often the current standard of care. Often the ICER is compared to a standard willingness-to-pay threshold, eg, $50,000 per life-year gained. Values of the ICER below the threshold, also known as the ceiling ratio, would be considered a socially acceptable healthcare expenditure to gain 1 year of life. Thus, in principal, any service that falls below the threshold would be considered cost effective. However, there is no socially acceptable threshold, there are uncertainties in the measurement of cost and efficacy, and society will often spend more than the threshold for patients in acute settings (rule of rescue). This has limited the use of cost-effectiveness analysis for determining policy. However, cost-effectiveness can expose the assumptions underlying our decisions, which can add setting policy.²

Utility Assessment

Utility is a measure of overall health and functioning, generally scaled from 0 to 1.³ Thus, for a patient with coronary artery disease suffering from angina, a utility of 0 would be death and 1 would be perfect health and ...