New research using data from the BEST-CLI trial found that bypass was associated with fewer major reinterventions and amputations, greater life-years and quality-adjusted life-years (QALYs) gained, and lower costs compared with endovascular surgery. The study, authored by Zafar Zafari (University of Maryland Institute for Health Computing, Bethesda, USA) and colleagues, was recently published online in JAMA Network Open.
To evaluate the cost-effectiveness of endovascular versus open surgical revascularisation for chronic limb-threatening ischaemia (CLTI), Zafari and team conducted an economic evaluation using data from 1,434 patients included in the multicentre, randomised BEST-CLI trial.
Specifically, the researchers developed an individual-level, continuous-time Markov model with health states based on adjudicated clinical events from the trial. Rates of clinical outcomes, health utilities, and healthcare resource use derived from trial data. The authors note that unit costs came from Medicare insurance claims data and the physician fee schedule.
In the team’s base-case analysis over five years, the mean per-person direct medical costs were US$118,559 for bypass surgery and US$125,535 for endovascular surgery. The mean survival per person was 3.84 years and 3.78 years for bypass and endovascular surgery, respectively, while the mean QALYs per person were 2.53 for bypass surgery and 2.48 for endovascular surgery.
In addition, the researchers found that bypass surgery dominated endovascular surgery with respect to both costs per life-year and per QALY gained. They note that the results over 10 years were consistent with those of the five-year BEST-CLI follow-up.
The team also conducted probabilistic analyses using a Monte Carlo simulation with 10,000 iterations, which revealed that there was a 93% chance bypass surgery was more cost-effective than endovascular surgery.
According to the authors, these findings suggest that bypass “may have superior outcomes at lower costs compared with endovascular surgical revascularisation”. However, they stress that “residual uncertainty remains, highlighting the need for further research to identify patient subgroups most likely to benefit from each strategy”.
