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Cost effectiveness of clinically appropriate decisions on alternative treatments for angina pectoris: prospective observational study

BMJ 2007; 334 doi: (Published 22 March 2007) Cite this as: BMJ 2007;334:624
  1. S C Griffin, research fellow1,
  2. J A Barber, lecturer in medical statistics2,
  3. A Manca, Wellcome Trust training fellow in health services research1,
  4. M J Sculpher, professor of health economics1,
  5. S G Thompson, professor of medical statistics3,
  6. M J Buxton, professor of health economics4,
  7. H Hemingway, professor of clinical epidemiology5
  1. 1Centre for Health Economics, University of York, York
  2. 2UCLH/UCL Biomedical Research Centre, University College London Hospitals NHS Trust, London, and Department of Statistical Science, University College London
  3. 3Medical Research Council Biostatistics Unit, Cambridge
  4. 4Health Economics Research Group, Brunel University, London
  5. 5Department of Epidemiology and Public Health, University College London Medical School, London WC1E 6BT
  1. Correspondence to: H Hemingway h.hemingway{at}
  • Accepted 23 January 2007


Objective To assess whether revascularisation that is considered to be clinically appropriate is also cost effective.

Design Prospective observational study comparing cost effectiveness of coronary artery bypass grafting, percutaneous coronary intervention, or medical management within groups of patients rated as appropriate for revascularisation.

Setting Three tertiary care centres in London.

Participants Consecutive, unselected patients rated as clinically appropriate (using a nine member Delphi panel) to receive coronary artery bypass grafting only (n=815); percutaneous coronary intervention only (n=385); or both revascularisation procedures (n=520).

Main outcome measure Cost per quality adjusted life year gained over six year follow-up, calculated with a National Health Service cost perspective and discounted at 3.5%/year.

Results Coronary artery bypass grafting cost £22 000 (€33 000; $43 000) per quality adjusted life year gained compared with percutaneous coronary intervention among patients appropriate for coronary artery bypass grafting only (59% probability of being cost effective at a cost effectiveness threshold of £30 000 per quality adjusted life year) and £19 000 per quality adjusted life year gained compared with medical management among those appropriate for both types of revascularisation (probability of being cost effective 63%). In none of the three appropriateness groups was percutaneous coronary intervention cost effective at a threshold of £30 000 per quality adjusted life year. Among patients rated appropriate for percutaneous coronary intervention only, the cost per quality adjusted life year gained for percutaneous coronary intervention compared with medical management was £47 000, exceeding usual cost effectiveness thresholds; in these patients, medical management was most likely to be cost effective (probability 54%).

Conclusions Among patients judged clinically appropriate for coronary revascularisation, coronary artery bypass grafting seemed cost effective but percutaneous coronary intervention did not. Cost effectiveness analysis based on observational data suggests that the clinical benefit of percutaneous coronary intervention may not be sufficient to justify its cost.


  • SCG and JAB contributed equally to this paper.

  • Contributors: All authors made substantial contributions to conception and design (health economic: MJS, MJB, SCG, and AM; statistical: SGT and JAB; clinical epidemiology: HH) and analysis (SCG and JAB). All authors contributed to interpretation of data, drafting the article or revising it critically for important intellectual content, and final approval of the version to be published. HH, JAB, MJS, MJB, and SGT obtained funding. HH is the principal investigator on the ACRE study and is the guarantor. Adam Timmis contributed to the conception and design (clinical cardiology) and interpretation of data. Angela Crook and Roger Stafford prepared the data. Sue Philpott and Natalie Fitzpatrick were the project coordinators.

  • Funding: British Heart Foundation project grant. The British Heart Foundation had no role in study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication. HH and MJS hold public health career scientist awards from the Department of Health. During the course of the ACRE cost effectiveness analysis study, AM became recipient of a Wellcome Trust training fellowship in health services research.

  • Competing interests: None declared.

  • Ethical approval: The five local ethics committees: West Essex, South Essex, Redbridge and Waltham Forest, East London and the City, and Barking and Havering.

  • Accepted 23 January 2007
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