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COURAGE

COURAGE. Economic Results of the COURAGE Trial William S. Weintraub, MD Chief of Cardiology Christiana Care Health System Professor of Medicine, Thomas Jefferson University. Health Care Economics. Purpose: To compare resource utilization across treatment arms

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COURAGE

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  1. COURAGE Economic Results of the COURAGE Trial William S. Weintraub, MD Chief of Cardiology Christiana Care Health System Professor of Medicine, Thomas Jefferson University

  2. Health Care Economics • Purpose: • To compare resource utilization across treatment arms • To compare costs across treatment arms • If one therapy offers better outcome at higher cost, perform an incremental cost-effectiveness analysis in cost per quality adjusted life year gained

  3. Health Care Economics • Methods: • DRG applied to hospitalization, CPT codes to outpatient care, 2004 codes • Costs from Medicare reimbursement • Medication costs from Red Book AWP • Average Medicare costs beyond trial period • Quality adjustment measuring utility with standard gamble • Survival estimates based on Framingham • Distribution of cost and outcome by bootstrap analysis

  4. In-Trial and Cumulative Costs

  5. Life Expectancy (Framingham)

  6. Utility

  7. LYs or QALYs gained with PCI Cost PCI Group (n=1149) Cost OMT Group (n=1138) (PCI - OMT) ICER %< $50,000 /LYG %< $100,000 /LYG In-trial, LY (3% discount) $34,843 $24,718 $10,125 0.0338 299,518 0 14.0 In-trial, QALY (3% discount) $34,843 $24,718 $10,125 0.0491 206,229 0 17.0 Lifetime, LY (3% discount) $99,820 $90,370 $9,451 0.036 262,116 3.3 25.7 Lifetime, QALY (3% discount) $99,820 $90,370 $9,451 0.056 168,019 10.1 35.4 Cost-Effectiveness Analysis

  8. 15000 ICER point estimate: $168,019/QALY gained 10000 (cost difference: $9,451, QALY difference: 0.036) 5000 Mean Cost Difference (PCI-Medical Therapy in $) $50,000/QALY gained threshold 0 -5000 $100,000/QALY gained threshold -10000 -15000 -0.2 -0.1 0.0 0.1 0.2 0.3 Mean Effectiveness Difference (PCI-Medical Therapy) Joint Distribution of Cost & Effectiveness Differences Lifetime Timeframe, Cost/QALY Gained

  9. 0.6 0.5 0.4 0.3 Probability of ICER Below Threshold 0.2 0.1 0.0 0 50,000 100,000 150,000 200,000 Incremental CE Ratio Threshold ($) Cost-Effectiveness Acceptability Curve Lifetime Timeframe, Cost/QALY Gained

  10. 1.6 1.4 1.2 Mean Cost Difference (PCI-Medial Therapy in $10000s) 1.0 0.8 0.6 0.4 0.5 -0.5 0.0 Mean Effective Difference in QALYs (PCI-Medical Therapy) Joint Distribution of Cost & Effectiveness Differences Bayesian Probabilistic Sensitivity Analysis Lifetime Timeframe, Cost/QALY Gained 50% 95% 99%

  11. Cost-Effectiveness Acceptability Curve Bayesian Probabilistic Sensitivity Analysis Lifetime Timeframe, Cost/QALY Gained 0.6 0.5 0.4 0.3 Probability of ICER Below Threshold 0.2 0.1 0.0 50,000 100,000 150,000 200,000 0 Incremental CE Ratio Threshold ($)

  12. Cost-Effectiveness Analysis for Improvement of Angina-Related Health Status At 6 Months PCI Group OMT Group Improvement In PCI Group Improvement In OMT Group (PCI - OMT) ICER Physical Limitation 386 (751) 300 (707) 51% 42% 9.0% $112,876 Angina Frequency 396 (787) 323 (738) 50% 44% 6.6% $154,580 Quality of Life 505 (786) 409 (729) 64% 56% 8.1% $124,233 Any 1 domain improvement 622 (792) 557 (741) 79% 75% 3.4% $300,742 Any 2 domain improvement 353 (792) 259 (741) 45% 35% 9.6% $105,272 All 3 domain improvement 222 (792) 147 (741) 28% 20% 8.2% $123,593

  13. Conclusions • PCI as an initial management strategy in the setting of stable CAD has not been shown to reduce the incidence of Death or MI • PCI has not been shown to prolong life expectancy • PCI+OMT does offer better control of angina than OMT alone • PCI+OMT was not shown to be a cost-effective initial management strategy for chronic CAD

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