FREEDOM Compares Cost-Effectiveness of DES-PCI and CABG

December 31, 2012—Results from the FREEDOM trial were published by Elizabeth A. Magnuson PhD, et al online ahead of print in Circulation. FREEDOM is an evaluation of the cost-effectiveness of percutaneous coronary intervention with drug-eluting stents (DES-PCI) versus coronary artery bypass graft surgery (CABG) for patients with diabetes and multivessel coronary artery disease (CAD).

Dr. Magnuson, of Saint Luke's Mid America Heart Institute in Kansas City, Missouri, presented the FREEDOM data on November 4, 2012, as a late-breaking clinical trial at the annual scientific sessions of the American Heart Association in Los Angeles, California.

According to the investigators, previous studies from the balloon angioplasty and bare-metal stent eras have demonstrated that CABG is cost effective compared with PCI for patients undergoing multivessel coronary revascularization, particularly among patients with complex CAD or diabetes; however, it has not been known whether these results apply in the era of DES.

From their findings, the investigators concluded that despite higher initial costs, CABG is a highly cost-effective revascularization strategy compared with DES-PCI for patients with diabetes and multivessel CAD.

As summarized in Circulation, the FREEDOM trial randomized 1,900 patients with diabetes and multivessel CAD to DES-PCI (n = 953) or CABG (n = 947) between 2005 and 2010. Costs were assessed from the perspective of the United States health care system. Health state utilities were assessed using the EuroQOL. A patient-level microsimulation model based on United States life tables and in-trial results was used to estimate lifetime cost-effectiveness. Although initial procedural costs were lower for CABG, total costs for the index hospitalization were higher, by $8,622 per patient.

The investigators reported that during the next 5 years, follow-up costs were higher with PCI, owing to more frequent repeat revascularization and higher outpatient medication costs. Nonetheless, cumulative 5-year costs remained $3,641 per patient higher with CABG. Although there were only modest gains in survival with CABG during the trial period, when the in-trial results were extended to a lifetime horizon, CABG was projected to be economically attractive relative to DES-PCI, with substantial gains in both life expectancy and quality-adjusted life expectancy and incremental cost-effectiveness ratios less than $10,000 per life-year or quality-adjusted life-year gained across a broad range of assumptions regarding the effect of CABG on posttrial survival and costs, according to published data in Circulation.